A nurse is caring for a child in the emergency department (ED).

Exhibits
For each potential intervention, click to specify if the potential intervention is expected or unexpected for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Have child tilt head back

Insert cotton into nostril

Apply ice to bridge of nose

Apply pressure to tip of nose for at least 10 min

Prepare to administer factor VIII

Prepare to administer topical antifibrinolytic agent

Prepare to administer packed red blood cells

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Potential Intervention	Expected	Unexpected	Rationale
Have child tilt head back		✅	Tilting the head back increases the risk of blood being swallowed, which can cause nausea or aspiration.
Insert cotton into nostril		✅	Cotton can be ineffective and may dislodge, worsening bleeding. Use gauze or a nasal tampon if needed.
Apply ice to bridge of nose	✅		Cold vasoconstricts blood vessels, helping reduce nasal bleeding.
Apply pressure to tip of nose for at least 10 min	✅		First-line measure for anterior epistaxis. Correct site is the soft part (lower third) of the nose.
Prepare to administer factor VIII	✅		The child has a Factor VIII deficiency (35%), which is diagnostic of Hemophilia A. Factor VIII replacement is the treatment.
Prepare to administer topical antifibrinolytic agent	✅		These agents help stabilize clots and are used for mucosal bleeds in hemophilia.
Prepare to administer packed red blood cells		✅	Not indicated unless there is severe blood loss with signs of anemia or hemodynamic instability, which is not present here.

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Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}

Explanation

When planning care for the infant, the nurse should prepare the infant for a rectal biopsy and frequently measure abdominal circumference.

Rationale for correct answers:

Prepare the infant for a rectal biopsy: Confirms diagnosis of Hirschsprung disease, which is suspected based on symptoms and enema findings.

Frequently measure abdominal circumference: Monitors abdominal distension, a key sign in bowel obstruction or worsening condition.

Rationale for incorrect answers:

Explain the purpose of the pyloromyotomy: This procedure is for pyloric stenosis, not Hirschsprung disease.

Transport the client for a radiologist guided gas enema: Contrast enema already performed.

Administer oral laxatives: Contraindicated in suspected bowel obstruction like Hirschsprung disease.

A. Steatorrhea B. Jaundice C. Incontinence D. Rebound tenderness

Correct Answer is C

Explanation

A. Steatorrhea

This refers to fatty, foul-smelling stools and is associated with malabsorption syndromes (e.g., celiac disease), not UTIs.

B. Jaundice

Jaundice is typically associated with liver or hemolytic conditions. It is not a symptom of a urinary tract infection.

C. Incontinence

In a toilet-trained toddler, new or increased episodes of incontinence may indicate a UTI. Toddlers may have difficulty expressing pain or urinary urgency, so regression in toilet habits is often a key indicator.

D. Rebound tenderness

Rebound tenderness indicates peritoneal irritation, seen in conditions like appendicitis—not in uncomplicated UTIs.

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A nurse is caring for a child in the emergency department (ED). Exhibits For each potential intervention, click to specify if the potential intervention is expected or unexpected for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant on an inpatient pediatric unit. Select words from the choices below to fill in each blank in the following sentence. Exhibits When planning care for the infant, the nurse should dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"D"}

Explanation

A nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5° C (101.3° F). Which of the following findings should the nurse recognize as an indication of a urinary tract infection (UTI)?

Correct Answer is C

Explanation

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A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include?

A nurse is providing teaching to the parent of a school-age child who has pediculosis capitis. Which of the following instructions should the nurse Include in the teaching?

A nurse is caring for a client in an outpatient orthopedist's office. Exhibits Complete the following sentence by using the lists of options. The toddler is at risk for developing dropdown as evidenced by the toddler's dropdown.

A nurse is admitting a child who has bacterial meningitis. Which of the following actions should the nurse take first?

A nurse is caring for a child in the post-anesthesia care unit (PACU) Exhibits The nurse should first dropdown due to the child's dropdown

A nurse is caring for a child in the emergency department (ED).

Exhibits
For each potential intervention, click to specify if the potential intervention is expected or unexpected for the client. There must be at least 1 selection in every row. There does not need to be a selection in every column.