Chapter 51: Alteration in Behavior, Cognition, or Development

Question 1

1. The nurse is caring for a 6-year-old girl who was injured in a bicycle accident. Which question would be most important for the nurse to ask during the health history?
   A) “Has she been diagnosed with any chronic disorders?”
   B) “Is your daughter currently taking any medications?”
   C) “Is she allergic to any medications or drugs?”
   D) “Tell me how the bicycle accident happened.”

Answer 1

Ans: D
Rationale: The priority inquiry is to determine the nature of the emergency so that appropriate interventions may be initiated. This will also provide direction for obtaining more in depth information as time permits. Information about allergic reactions to drugs, medications being taken, and chronic disorders that may affect treatment will be gathered next.

Question 2

2. The nurse is caring for a 7-year-old boy experiencing respiratory distress who is scheduled to have a chest radiograph. What would be most important for the
   nurse to include in the child’s plan of care?
   A) Administering a sedative to help calm the child
   B) Assisting the child to lie still during the chest radiograph
   C) Accompanying the child to continue observation
   D) Informing the child that he might hear a loud banging noise

Answer 2

Ans: B
Rationale: Chest radiographs that disclose alterations in normal anatomy or lung expansion, or evidence of pneumonia, tumor, or foreign body, are commonly performed for respiratory emergencies. Therefore, the nurse would need to assist the child in remaining still during the procedure. A sedative may be ordered for magnetic
resonance imaging (MRI). Accompanying the child to continue observation would be necessary if the child was to undergo a computed tomography scan. Telling the child about a loud banging noise would be appropriate if the child was having an MRI.

Question 3

3. A 5-year-old girl is cyanotic, dusky, and anxious when she arrives in the emergency department. Which action would be most appropriate?
   A) Ventilating the child with a bag-valve-mask
   B) Estimating the child’s weight using a Broselow tape
   C) Providing therapy using automated external defibrillation
   D) Using rescue breathing and chest compressions

Answer 3

Ans: A
Rationale: The child is exhibiting signs of ineffective oxygenation and ventilation. Therefore, ventilating the child with a bag-valve-mask and 100% oxygen would be effective
and efficient. Estimating the child’s weight with a Broselow tape is typically done by ambulatory care providers. According to the American Heart Association, automated
external defibrillators are recommended for use in children who are older than age 1 year who have no pulse and have suffered a sudden, witnessed collapse outside the hospital setting. Rescue breathing and chest compressions are implemented for children who are not breathing and do not have a pulse or when the pulse rate is less than 60 beats per minute.

Question 4

4. When caring for an 8-year-old boy injured in an automobile accident, the nurse demonstrates understanding of the principles of Pediatric Advanced Life
   Support (PALS) by which action?
   A) Assisting ventilation with a bag-valve-mask (BVM) device
   B) Treating ventricular fibrillation using a defibrillator
   C) Managing compensated shock to prevent decompensated shock
   D) Treating supraventricular tachycardia using cardioversion

Answer 4

Ans: C
Rationale: The principles of PALS stress evaluating and managing compensated shock with the goal of preventing decompensated shock and thereby preventing cardiopulmonary arrest. Assisting ventilation with a BVM device, treating ventricular fibrillation using a defibrillator, and treating supraventricular tachycardia using cardioversion are interventions that may be used to treat both children and adults.

Question 5

5. A 9-year-old girl who has fallen from a second-story window is brought to the emergency department. Which assessment would be the priority?
   A) Evaluating pupils for equality and reactivity
   B) Monitoring oxygen saturation levels
   C) Asking the child if she knows where she is
   D) Using the appropriate pain assessment scale

Answer 5

Ans: B
Rationale: Airway is always the priority in any emergency situation. Therefore, monitoring oxygen saturation levels, part of the rapid cardiopulmonary assessment, would be
performed before any of the other assessments. Evaluating pupils for equality and reactivity, asking the child if she knows where she is, and using an appropriate pain
assessment scale are assessments that would follow the ABCs.

Question 6

6. The parents bring their 3-year-old son to the emergency department after he ingested some of his mother’s medicine. Which assessment would be of critical
   importance for this child?
   A) Assessing mental status and skin moisture and color
   B) Evaluating the effectiveness of the child’s breathing
   C) Noting the child’s pulse rate and quality
   D) Auscultating all lung fields for signs of edema

Answer 6

Ans: A
Rationale: In cases of poisoning, clinical manifestations vary widely depending on the medication or chemical ingested. Therefore, it is important to pay particular attention to the child’s mental status, skin moisture and color, and bowel sounds. Evaluating the effectiveness of the child’s breathing and noting the child’s pulse rate and quality are basic to any rapid cardiopulmonary assessment. Auscultating all lung fields for signs of pulmonary edema would be critically important for a child who is a near-drowning victim.

Question 7

7. What would the nurse do first for a 5-year-old girl with profound bradycardia?
   A) Provide oxygen at 100%
   B) Administer epinephrine as ordered
   C) Use warming blankets
   D) Perform gastric lavage

Answer 7

Ans: A
Rationale: The most common cause of profound bradycardia is respiratory compromise, hypoxia, and shock; thus, oxygenation and ventilation are the priorities. If the bradycardia persists, the next step would be to administer epinephrine or atropine as ordered. Hypothermia or toxic ingestion can cause bradycardia. Treating the underlying problem will relieve the bradycardia.

Question 8

8. Which measure would be most appropriate for the nurse to do to ensure that a child’s endotracheal (ET) tube is correctly positioned?
   A) Auscultate for abdominal breath sounds
   B) Mark the tracheal tube at the child’s lip
   C) Watch for a yellow display on a CO2 monitor
   D) Inspect for water vapor in the tracheal tube

Answer 8

Ans: C
Rationale: The best way to verify correct tracheal tube placement is to use a CO2 monitor. If the tube is properly placed, the monitor display will turn yellow with each
exhalation. Auscultation for breath sounds and inspecting the tube for signs of water vapor are valid confirmations, but not as good as CO2 monitors. Marking the tube alerts the nurse if the tube becomes misplaced.

Question 9

9. Which intervention would be most helpful in preventing barotrauma when ventilating a 3-year-old girl with a bag-valve-mask?
   A) Choosing the correct size bag and face mask
   B) Setting the flow rate at exactly 10 L/min
   C) Maintaining the airway in the open position
   D) Delivering one breath every 3 to 5 seconds

Answer 9

Ans: D
Rationale: Barotrauma is often the result of healthcare provider or nurse practitioners ventilating the child too rapidly using too much tidal volume. Therefore, delivering
one breath every 3 to 5 seconds is the best way to prevent barotrauma. Choosing the correct size bag and face mask and setting the correct flow rate are important for effective ventilation, as is maintaining the airway in the open position. However, these actions would have little impact on preventing barotrauma.

Question 10

10. The nurse is providing care to a 4-year-old boy with a broken arm and an infected laceration from a fall. The nurse notes a significant elevation in the child’s heart rate. Which intervention would be least appropriate?
    A) Administering antipyretics as ordered for fever
    B) Using a defibrillator to reduce the heart rate
    C) Administering analgesics to reduce pain
    D) Allowing the parents to comfort the child

Answer 10

Ans: B
Rationale: Fever, fear, and pain are common explanations for significant increases in the heart rate of a child. This normal elevation in heart rate is known as sinus tachycardia
and can be managed by treating the underlying causes. Antipyretics, analgesics, and comfort from the parents would be appropriate. However, defibrillation should be avoided.

Question 11

11. A child weighing 51 lb (23.1 kg) requires defibrillation. How many joules would the nurse expect to give initially?
    A) 46
    B) 92
    C) 102
    D) 204

Answer 11

Ans: A
Rationale: The initial amount of energy or joules for defibrillation is 2 joules/kg. The child weighs 51 lb, which is 23 kg, so 46 joules would be used.

Question 12

12. A 1-month-old infant admitted to the emergency department in respiratory distress exhibits a regular pattern of breathing followed by brief periods of apnea, then tachypnea for a short time, eventually returning to a normal respiratory rate.
    This type of breathing is:
    A) hypoventilation.
    B) hyperventilation.
    C) periodic breathing
    D) stridor.

Answer 12

Ans: C
Rationale: Periodic breathing is regular breathing with occasional short pauses followed by rapid breathing for a short period, then eventually resumption of a normal respiratory rate. Hypoventilation refers to a decrease in the depth and rate of respirations. Hyperventilation refers to an increased depth and rate of respirations. Stridor refers to a high-pitched, easily audible inspiratory noise.

Question 13

13. The nurse is gathering the necessary equipment for tracheal intubation for a child who is 2 years old. Which tracheal tube size would the nurse obtain?
    A) 4.5
    B) 5
    C) 5.5
    D) 6

Answer 13

Ans: A
Rationale: To calculate tracheal tube size, divide the child’s age by 4 and add 4. For a 2-year-old child, 2 divided by 4 equals 0.5 plus 4 equals 4.5. The nurse also should have
one size smaller ready.

Question 14

14. What would lead the nurse to suspect that a 5-year-old child is experiencing supraventricular tachycardia?
    A) Heart rate 160 beats per minute
    B) Flattened P waves
    C) Normal QRS complex
    D) History of fever

Answer 14

Ans: B
Rationale: Supraventricular tachycardia is manifested by flattened P waves, a heart rate greater than 180 beats per minute, a narrow QRS complex, and usually no significant history. A heart rate of 160 beats per minute, normal QRS complex, and history of fever, fluid loss, hypoxia, pain, or fear would suggest sinus tachycardia.

Question 15

15. What would be most appropriate to use to help maintain a patent airway in an infant experiencing a respiratory emergency?
    A) Neck hyperextension
    B) Head tilt–chin lift technique
    C) Jaw-thrust maneuver
    D) Small towel under shoulders

Answer 15

Ans: D
Rationale: The infant will benefit from a small sheet or towel folded under the shoulders. This facilitates keeping the infant’s airway in the sniff position as recommended by the
American Heart Association’s Basic Cardiac Life Support guidelines. Neck hyperextension and flexion should be avoided because these may occlude the airway. The head tilt–chin lift technique is appropriate to open the airway of a child older than age 1 year if a cervical spine injury is not suspected. The jaw-thrust maneuver is used if there is concern about the cervical spine.

Question 16

16. After teaching a group of nursing students about shock in children, the instructor determines that the teaching was successful when the students identify which type of shock as most common?
    A) Septic
    B) Cardiogenic
    C) Hypovolemic
    D) Distributive

Answer 16

Ans: C
Although septic, cardiogenic, hypovolemic, and distributive shock can occur in children, hypovolemic shock is the most common type of shock that occurs in children.

Question 17

17. A child who weighs 53 lb is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child’s hourly urinary output to determine if the child’s condition is improving. Which output would the nurse interpret as most indicative of improvement?
    A) 12 mL
    B) 15 mL
    C) 22 mL
    D) 30 mL

Answer 17

Ans: D
Rationale: Improved urinary output of 1 to 2 mL/kg/hour is the goal. The child weighs 53 lb, which is equivalent to 24 kg. Thus, improvement in this child would be noted by an
hourly urinary output between 24 and 48 mL/hour.

Question 18

18. A child has a tracheal tube in place and will be receiving medications via this tube. Which medications would the nurse expect to be administered in this manner?
    Select all that apply.
    A) Lidocaine
    B) Adenosine
    C) Atropine
    D) Dopamine
    E) Epinephrine
    F) Naloxone

Answer 18

Ans: A, C, E, F
Rationale: Medications that may be administered via a tracheal tube include lidocaine, epinephrine, atropine, and naloxone. Adenosine is given intravenously; dopamine is
given intravenously or intraosseously.

Question 19

19. A group of students are reviewing information about respiratory arrest in children. The students demonstrate understanding of this information when they identify what common causes of respiratory arrest involving the upper airway? Select all that apply.
    A) Croup
    B) Asthma
    C) Pertussis
    D) Epiglottitis
    E) Pneumothorax

Answer 19

Ans: A, D
Rationale: Common causes of respiratory arrest involving the upper airway include croup and epiglottitis. Asthma, pertussis, and pneumothorax are common causes involving the lower airway.

Question 20

20. The nurse is preparing the plan of care for a child experiencing respiratory distress. What action would be the top priority?
    A) Providing supplemental oxygen
    B) Monitoring for changes in status
    C) Assisting ventilation
    D) Maintaining a patent airway

Answer 20

Ans: D
Rationale: The priority when caring for any child with respiratory distress is to maintain a patent airway. Although providing supplemental oxygen, monitoring for changes in status, and assisting with ventilation are important, these measures would be futile if the child’s airway was not patent.

Question 21

21. The nurse is providing care to a child who is intubated, and the child’s condition is deteriorating. What would the nurse do first?
    A) Check if the tracheal tube is obstructed
    B) Assess for displacement of the tracheal tube
    C) Look for signs of a possible pneumothorax
    D) Check the equipment for malfunction

Answer 21

Ans: B
Feedback:
The PALS mnemonic “DOPE” is useful for troubleshooting when the status of a child who is intubated deteriorates: D = Displacement: the tracheal tube is is displaced from the trachea; O = Obstruction: the tracheal tube is obstructed (e.g., with a mucus plug); P = Pneumothorax: usually a pneumothorax results in a sudden change in the child’s assessment manifested by decreased breath sounds and
decreased chest expansion on the side of the pneumothorax, possible subcutaneous emphysema over the chest (with a tension pneumothorax, there may be a sudden
drop in heart rate and blood pressure); E = Equipment failure: relatively simple problems such as a disconnected oxygen supply, leaks in the ventilator circuit, and
loss of power can cause the child to deteriorate.

Question 22

22. The nurse is providing care to a child experiencing shock. Which intravenous solution would the nurse expect to administer?
    A) Ringer lactate
    B) Dextrose 5% and water
    C) Dextrose 5% and normal saline
    D) Dextrose 10% and water

Answer 22

Ans: A
Rationale: Isotonic fluids, such as Ringer lactate or normal saline, are the fluids of choice given rapidly to children experiencing shock. Dextrose solutions are contraindicated in shock because of the risk of complications such as osmotic diuresis, hypokalemia, hyperglycemia, and worsening of ischemic brain injury

Question 23

23. A child is brought to the emergency department with a suspected poisoning. What treatment would the nurse least likely expect to be used?
    A) Gastric lavage
    B) Syrup of ipecac
    C) Activated charcoal
    D) Whole bowel irrigation

Answer 23

Ans: B
Rationale: Ipecac is rarely used in the health care setting to induce vomiting and is no longer recommended for use in the home setting. Gastric lavage, administration of activated charcoal (binds with the chemical substance in the bowel) , or whole bowel irrigation with polyethylene glycol electrolyte solutions may be used.

Question 24

24. A group of students are working on a presentation for a local health fair about safety for children. When developing this presentation, the students would address what cause as the most common in pediatric injury?
    A) Sports
    B) Firearm use
    C) Falls
    D) Automobile accidents

Answer 24

Ans: C
Rationale: Falls are the most common cause of pediatric injury. Automobile accidents continue to cause deaths of about five children daily. Childhood trauma also results from
pedestrian accidents, sporting and bicycle injuries, and firearm use.

Question 25

25. As part of their orientation to their pediatric clinical rotation, an instructor is teaching a group of students how to perform cardiopulmonary resuscitation (CPR) on a child. Two students return demonstrate the skill using an infant manikin. What action indicates the proper technique?
    A) Compressing 30 times for every 2 breaths
    B) Placing the heel of the hand on the midsternum
    C) Giving 2 breaths followed by 15 compressions
    D) Using two hands to perform chest compressions

Answer 25

Ans: C
Rationale: For two-person CPR on an infant, the rescuers would perform 15 compressions to 2 breaths, with two thumbs encircling the chest at the nipple line. The ratio of 30 compressions to 2 breaths is used for one-person CPR with an infant. The heel of the hand on the sternum at the nipple line is used for a child; two hands would be used for an older child.

Question 26

26. A child is undergoing rapid sequence intubation and is receiving atropine. The nurse understands that this agent is used to:
    A) lessen the vagal effects of intubation.
    B) reduce intracranial pressure.
    C) induce amnesia.
    D) provide short-term paralysis.

Answer 26

Ans: A
Rationale: Atropine is used to decrease respiratory secretions and mitigate the vagal effects of intubation. Thiopental reduces intracranial pressure and oxygen demand. Midazolam causes amnesia. Rocuronium or other neuromuscular blocking agents provide short-term paralysis during intubation.

Question 27

27. A nurse determines that a child is exhibiting compensated supraventricular tachycardia (SVT). What action would be attempted first?
    A) Adenosine
    B) Synchronized cardioversion
    C) Vagal maneuvers
    D) Amiodarone

Answer 27

Ans: C
Rationale: With compensated supraventricular tachycardia, vagal maneuvers are attempted first and then adenosine is used if vagal maneuvers fail. Adenosine or synchronized cardioversion is used to treat uncompensated SVT; synchronized cardioversion and IV amiodarone are used to treat ventricular tachycardia.

Question 28

28. The nurse is teaching a CPR course for a group of nursing students. Which responses indicate an understanding of the content provided regarding the AED?
    Select all that apply.
    A) “When considering the use of the AED, the child must weigh at least 30 lb (13.6 kg).”
    B) “An AED must only be employed if the collapse is witnessed.”
    C) “To use the device the child must be at least 1 year of age.”
    D) “The AED can be used only if the victim demonstrates no heart rate.”
    E) “The AED is safe for use prehospital.”

Answer 28

Ans: B, C, D, E
Rationale: An AED is an alternative to manually defibrillating an individual. The AED device consists of electrodes that are applied to the chest. These electrodes are used to monitor the heart rhythm and deliver the electrical current. AED devices are readily available in a variety of locations, such as airports, sports facilities, and businesses. Additionally, the AHA has recommended that an AED be used for children who are older than age 1 year who have no pulse and have suffered a sudden, witnessed collapse.

Question 29

29. A nurse has just transferred from an adult medical- surgical unit to a pediatric unit. When reviewing CPR skills, what it is important for the nurse to realize?
    A) The pediatric chain of survival and the adult chain of survival are the same.
    B) Prevention of cardiac arrest and injuries is the first step in the chain of survival for children.
    C) Integrated post–cardiac arrest care is not part of the chain of survival for children.
    D) Early CPR should occur before any steps of the chain of survival are considered.

Answer 29

Ans: B
Rationale: Prevention of cardiac arrest and injuries is the first step in the chain of survival in children in contrast to early emergency medical system (EMS) activation in adults.
Integrated post–cardiac arrest care is the last step in the chain for both adults and children. Early CPR is the second step in the chain for both adults and children.

Question 30

30. Two nurses are driving to work and have just come upon the scene of a motor vehicle accident (MVA) involving a child being hit by a car. The nurses decide to stop and find that only the child was injured. One of the nurses begins providing care. What is the first question the other nurse should ask the witnesses of the accident?
    A) “Can I get your name and numbers in case someone needs to contact you later?”
    B) “How did the accident happen?”
    C) “Do you know if the children have any health history I should know about?”
    D) “How long ago did someone activate the EMS?”

Answer 30

Ans: B
Rationale: The first question should be asking how the accident occurred in order to get an idea of the types of injuries the children may have sustained. All other questions
can be asked after establishing this information; however, asking names and numbers of the witnesses would be the last question asked by the nurse, and would most likely be asked by someone else