In the pediatric emergency department, the nurse must prioritize patient care. Which patient should the nurse assess first?

The 1-month-old infant who has developed colic and is crying.

The 14-year-old adolescent whose mother suspects her child is sexually active.

The 2-year-old toddler who was bitten by another child at the day-care center.

The 6-year-old school-aged child who was hit by a car while riding a bicycle.

Answer and Explanation

The Correct Answer is D

Choice A reason: While colic can be distressing, it is not life-threatening and does not require immediate assessment over more critical conditions.
Choice B reason: Suspicions of sexual activity in an adolescent are a concern but do not constitute an emergency that requires immediate assessment.
Choice C reason: A bite from another child, although potentially serious, is less urgent than a trauma case and can be assessed after more critical patients.
Choice D reason: This is the correct choice. A child hit by a car may have life-threatening injuries and requires immediate assessment and intervention.

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

Choice A reason: Administering oxygen helps increase the oxygen saturation during a 'tet' spell.
Choice B reason: The Trendelenburg position is not recommended for 'tet' spells as it does not help alleviate the hypercyanotic episode.
Choice C reason: While important for overall assessment, drawing blood for serum hemoglobin is not an immediate intervention during a 'tet' spell.
Choice D reason: Placing the infant in a knee-chest position increases systemic vascular resistance, which can help improve oxygenation.
Choice E reason: Administering morphine is appropriate as it helps to relax the infant, reducing the work of breathing and improving oxygenation.

A. Acute diarrhea; dehydration. B. Failure to pass meconium; abdominal distension. C. Projectile vomiting; altered electrolytes. D. Currant jelly-like gelatinous stools; pain.

Correct Answer is B

Explanation

Choice A reason: Acute diarrhea and dehydration are not typical of Hirschsprung disease, which is characterized by bowel obstruction.
Choice B reason: This is the correct choice. Failure to pass meconium within the first 48 hours of life and abdominal distension are classic signs of Hirschsprung disease.
Choice C reason: Projectile vomiting and altered electrolytes could be signs of other conditions but are not specific to Hirschsprung disease.
Choice D reason: Currant jelly-like gelatinous stools and pain are more indicative of intussusception rather than Hirschsprung disease. Hirschsprung disease typically presents with a failure to pass stool and abdominal distension.

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In the pediatric emergency department, the nurse must prioritize patient care. Which patient should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An infant with tetralogy of Fallot is having a hypercyanotic episode ('tet' spell). Which three nursing interventions are appropriate for the nurse to implement for this infant?

Correct Answer is ["A","D","E"]

Explanation

A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on assessment support this newborn’s diagnosis?

Correct Answer is B

Explanation

A school-age client diagnosed with diabetes insipidus (DI) is admitted to the pediatric unit. Which laboratory value does the nurse anticipate for this client based on the diagnosis?

A nurse is conducting a postoperative assessment on an infant who has just had a ventriculoperitoneal shunt placed for hydrocephalus. Which assessment finding would indicate a malfunction in the shunt?

The nurse is assessing a patient’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

At which stage of development are children able to understand the permanence of death?

Which statement by the nurse would best help alleviate parental guilt about their child, George, who has been recently diagnosed with autism?

A mother brings her two-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago. Based on this information, which is the most appropriate action by the nurse?