NCLEX Practice Exam for Pediatric Nursing 3

EXPLANATION

✔Correct answer:

Contact the poison control center for instructions. If a child ingests a potentially toxic substance, the first and most appropriate action is to immediately contact the poison control center (in the U.S., 1-800-222-1222). Poison control specialists can quickly assess the type of substance, the amount ingested, and the child's condition, and provide specific, evidence-based instructions tailored to the situation.

This step is critical because treatment varies significantly depending on the chemical or drug involved. Some substances may require urgent medical attention, while others may not pose a serious risk. In many cases, intervening without proper guidance can cause more harm, such as inducing vomiting with caustic substances.

Think of poison control like calling a GPS when you're lost in an unfamiliar city—you need quick, accurate directions based on where you are, not random guesses. The poison control center gives the safest and fastest route to help.

Pediatric nurses should educate caregivers on poison prevention and response strategies to reduce the risk of accidental poisoning and ensure prompt, effective care when needed.

• Teach parents to keep all medications, cleaning products, and toxic substances in locked or high cabinets.
• Emphasize that calling poison control is faster and more accurate than searching online or acting impulsively.
• Ensure caregivers understand the importance of saving product labels or containers to share exact information with poison control.
• Encourage keeping the poison control center number readily visible or saved in their phone.
• Stress the importance of supervising toddlers, who are naturally curious and prone to oral exploration.

✘Incorrect answer options:

Give the child ipecac syrup right away. This practice is no longer recommended. Inducing vomiting can be dangerous, especially with corrosive substances, hydrocarbons, or if the child is drowsy or having seizures. Ipecac syrup is no longer advised and has been removed from many home medicine cabinets.

Immediately call for emergency medical services. While calling 911 is necessary in life-threatening situations (e.g., unconsciousness, seizures, difficulty breathing), most poisonings do not require EMS activation right away. Poison control should be the first contact unless the child is unstable.

Discipline the child to discourage future incidents. Disciplining a toddler after accidental ingestion is inappropriate and ineffective. At this developmental stage, the focus should be on prevention and supervision, not punishment.

EXPLANATION

✔Correct answer:

Use the heel of one hand to perform chest compressions. When performing cardiopulmonary resuscitation (CPR) on a child aged 1 to puberty—such as 4-year-old Mia—the recommended technique for chest compressions is to use the heel of one hand placed over the lower half of the sternum. For larger or older children, two hands may be used if needed to achieve adequate compression depth. The compression depth should be approximately 2 inches (5 cm), not exceeding 2.4 inches (6 cm), and compressions should be delivered at a rate of 100–120 per minute.

This technique ensures effective circulation while accommodating the child’s smaller thoracic anatomy compared to an adult. Using only the fingers (as in infant CPR) would not generate sufficient pressure, and using both hands as in adult CPR might be excessive and potentially harmful if not indicated by the child’s size.

Think of chest compressions like pumping a bicycle tire—you need just the right amount of pressure and placement. Too little, and the tire stays flat (no circulation); too much, and you risk popping it (injury). One hand gives just the right control for a 4-year-old.

CPR technique must be adjusted based on patient age, size, and number of rescuers available.

• Use the heel of one hand for compressions in most children aged 1 to puberty; use two hands if needed for adequate depth.
• Compress at a depth of about 2 inches (5 cm), allowing full chest recoil between compressions.
• Ensure a compression-to-ventilation ratio of 30:2 for a single rescuer and 15:2 for two rescuers.
• Provide rescue breaths over 1 second, enough to see visible chest rise.
• Follow the Pediatric Advanced Life Support (PALS) guidelines and ensure regular CPR training updates.

✘Incorrect answer options:

Use both hands to compress the sternum at a depth of 1½ to 2 inches (4 to 5 cm). Using both hands is typically reserved for adults or larger children when one hand is not sufficient. While the depth is nearly correct, the use of both hands for a small 4-year-old may be excessive unless needed for adequate compression.

Provide rescue breaths at a rate of 12 per minute. This rate is appropriate for children with a pulse but not breathing adequately, not during full CPR. During CPR, breaths are given based on the compression-to-ventilation ratio, not per-minute respiratory rate.

Perform CPR only with the assistance of a second rescuer. While having a second rescuer is ideal, single-rescuer CPR is absolutely appropriate and often necessary. CPR should never be delayed while waiting for help.

EXPLANATION

✔Correct answer:

A 10% glucose solution. When administering total parenteral nutrition (TPN) via a peripheral IV line, the concentration of dextrose (glucose) must be carefully considered to prevent chemical phlebitis, vein irritation, or infiltration. A 10% glucose (dextrose) solution is generally considered the maximum safe concentration for peripheral administration. It strikes a balance between minimizing vein irritation and providing adequate caloric intake, making it appropriate for short-term or partial TPN therapy in children like Marco.

Higher concentrations of dextrose are hyperosmolar and can damage peripheral veins. For long-term or higher-calorie TPN needs, a central venous line is preferred, where higher dextrose concentrations (15–25%) can be administered safely due to rapid dilution in central circulation.

Think of the peripheral vein like a narrow country road—too much heavy traffic (high glucose concentration) will break it down. A 10% glucose solution is like a steady, manageable stream of cars—safe and efficient without causing damage.

Peripheral TPN must be managed with vigilance to prevent complications and ensure effective nutrition.

• Verify the TPN formulation includes no more than 10% glucose if administered peripherally.
• Assess the IV site frequently for redness, swelling, or signs of phlebitis or infiltration.
• Monitor blood glucose levels, electrolytes, and fluid balance regularly.
• Collaborate with the physician or nutritionist if higher caloric needs suggest a shift to central line access.
• Ensure TPN solution is labeled correctly and that infusion rates are set as prescribed.

✘Incorrect answer options:

A 5% glucose solution. While safe for peripheral veins, a 5% dextrose solution does not provide sufficient caloric density for TPN in pediatric patients. It may be used for basic maintenance fluids but not for meeting full nutritional needs.

A 15% glucose solution. This concentration is too hyperosmolar for peripheral administration and increases the risk of vein damage. It is suitable only for central venous administration.

A 17% glucose solution. Like 15%, this level of glucose exceeds peripheral vein tolerance and is reserved for central lines such as PICC or subclavian catheters.

EXPLANATION

✔Correct answer:

A potential latex allergy. Ava's allergic reactions to bananas, kiwifruit, and colorful balloons—combined with her diagnosis of spina bifida—strongly suggest a latex allergy. Children with spina bifida are at particularly high risk for developing latex sensitivity due to frequent early and repeated exposure to latex-containing medical products such as gloves, catheters, and tubing during procedures and hospitalizations.

Furthermore, the reactions to bananas and kiwifruit are examples of cross-reactivity, which is common in individuals with latex allergy. This phenomenon is known as latex-fruit syndrome, where the proteins in certain fruits (bananas, kiwis, avocados, chestnuts, etc.) are structurally similar to those in natural rubber latex, triggering an allergic response.

Think of the immune system like a security alarm. If it reacts to latex, it might also go off when it sees “look-alike intruders” like banana and kiwi proteins—mistaking them for latex and triggering the same allergic response.

Latex allergy can be life-threatening; thus, early identification and strict avoidance are essential.

• Ensure that Ava’s chart is clearly marked for latex allergy and notify all members of the healthcare team.
• Educate the family to avoid latex products at home, such as latex balloons, rubber gloves, and pacifiers with rubber nipples.
• Teach parents about foods commonly associated with latex cross-reactivity (bananas, kiwis, avocados, chestnuts, etc.).
• Provide an emergency action plan and possibly prescribe an epinephrine auto-injector if reactions have been severe.
• Encourage use of non-latex alternatives in all medical and childcare settings.

✘Incorrect answer options:

A food-related sensitivity to bananas. While Ava shows a reaction to bananas, this is not an isolated food allergy. The presence of multiple related food sensitivities and a reaction to latex-containing items suggests a broader latex allergy with food cross-reactivity.

An isolated reaction to kiwifruit. Again, this minimizes the pattern of reactions and ignores the clinical context of spina bifida, which places Ava at higher risk for latex allergy.

A possible allergy to artificial color dyes. Color dyes may cause reactions in some children, but they are not linked to latex-fruit syndrome. Ava’s symptoms specifically after playing with latex balloons and eating fruits known for latex cross-reactivity point more clearly to a latex allergy.

EXPLANATION

✔Correct answer:

Routinely measuring the infant’s head circumference. Infants with spina bifida, particularly the myelomeningocele type, are at high risk for developing hydrocephalus due to associated malformations like Arnold-Chiari II, which can obstruct cerebrospinal fluid (CSF) flow. The most practical, noninvasive, and essential bedside assessment for detecting early signs of hydrocephalus is routine measurement of head circumference.

A rapid or abnormal increase in head size is often the earliest indicator of accumulating CSF. This measurement is plotted on a standardized growth chart to monitor trends over time. Consistent and accurate tracking allows the nurse to identify deviations from normal growth patterns, prompting timely intervention before neurological damage occurs.

Just like checking the water level in a tank tells you if it’s overflowing, measuring head circumference regularly tells you if fluid (CSF) is building up inside the brain. A sudden increase signals a problem—before you see other symptoms.

Nurses play a critical role in early hydrocephalus detection, especially in high-risk infants like those with spina bifida.

• Measure and document head circumference at regular intervals using a non-stretchable tape measure.
• Compare measurements to age-appropriate growth charts to detect abnormal increases.
• Monitor for additional signs of increased intracranial pressure (e.g., bulging fontanel, vomiting, irritability, sunset eyes).
• Report significant deviations in head growth promptly to the healthcare provider.
• Educate caregivers about signs of hydrocephalus and the importance of follow-up care.

✘Incorrect answer options:

Ordering a skull X-ray to assess bone structure. Skull X-rays are not sensitive enough to detect hydrocephalus in its early stages. They do not provide direct information about CSF accumulation or ventricular enlargement.

Conducting a lumbar puncture to check cerebrospinal fluid. While a lumbar puncture can analyze CSF, it is invasive, and not routinely performed just for screening. It is usually done after signs or symptoms appear, not as a preventive assessment.

Scheduling a magnetic resonance imaging (MRI) scan. An MRI can confirm hydrocephalus, but it is not the most practical first-line tool due to cost, need for sedation in infants, and limited availability. Head circumference monitoring allows early detection, which can then be followed up with imaging.

EXPLANATION

✔Correct answer:

Both the anterior and posterior fontanels are closed. By 19 months of age, a healthy toddler should have closure of both the anterior and posterior fontanels. The posterior fontanel typically closes first, usually by 6 to 8 weeks of age. The anterior fontanel—the larger and more clinically significant one—closes later, generally between 12 to 18 months. Therefore, during a routine exam of a 19-month-old, Nurse Kennedy should expect that both fontanels have closed as part of normal cranial development.

Fontanel closure is influenced by the growth of the brain and skull bones, and delayed or premature closure can indicate underlying conditions such as hypothyroidism, hydrocephalus, or craniosynostosis. However, closure by this age is expected and appropriate.

Think of the fontanels like construction zones in the skull where growth is happening. By 19 months, the construction is complete, and the "skylights" (fontanels) are sealed up because the brain has developed to the point where those open spaces are no longer needed.

Regular assessment of fontanel status is part of monitoring developmental progress and neurological health.

• Document fontanel status accurately, noting if closure is delayed or premature.
• Refer to a pediatric provider if fontanels are unusually tense, bulging, sunken, or remain open beyond expected timeframes.
• Assess head circumference trends over time to detect abnormal skull growth patterns.
• Educate parents on what to expect in terms of head growth and fontanel closure during well-baby visits.
• Be alert for signs of increased intracranial pressure, especially if fontanels are abnormally bulging in a child with other symptoms (vomiting, irritability, poor feeding).

✘Incorrect answer options:

A closed anterior fontanel and an open posterior fontanel. This pattern is abnormal for a 19-month-old. The posterior fontanel normally closes by 2 months of age, so it should not be open at this stage.

An open anterior fontanel and a closed posterior fontanel. By 19 months, the anterior fontanel should also be closed. If still open, it may suggest delayed closure, which warrants further evaluation.

Both the anterior and posterior fontanels are open. This is not normal at 19 months and may indicate developmental delay, increased intracranial pressure, or a metabolic or genetic disorder.

EXPLANATION

✔Correct answer:

The foster parent who currently has legal custody of Lucas. In pediatric nursing, obtaining informed consent for medical procedures, such as a blood transfusion, is a legal and ethical requirement. When a child is in foster care, the authority to provide consent lies with the individual or agency that holds legal custody. In this scenario, the foster parent with legal guardianship has the right to sign the consent form, assuming there is no court order limiting that authority.

Legal custody includes the right to make decisions about the child’s healthcare, education, and general welfare. If foster parents have been legally granted this role, they are responsible for consenting to procedures that are in the child’s best interest.

Think of legal custody like having a signed permission slip. Even if others care about the child or are involved in their life, only the person holding that permission slip can legally authorize actions—just like only someone with legal custody can authorize medical procedures.

Nurses must carefully verify consent in pediatric cases to protect the patient’s rights and comply with legal standards.

• Always confirm and document who holds legal custody before proceeding with any treatment requiring informed consent.
• Collaborate with the healthcare team and hospital legal or social services when the consent process is unclear.
• Educate foster caregivers about the procedure, ensuring they understand the risks, benefits, and alternatives.
• Ensure the consent is obtained prior to the procedure and witnessed as per hospital policy.
• Advocate for the child’s best interests, particularly when navigating complex custody or legal arrangements.

✘Incorrect answer options:

The pediatric nurse caring for Lucas during the hospital stay. While nurses are integral to care delivery, they cannot legally provide informed consent on behalf of a patient. Their role is to ensure consent is obtained from the appropriate legal guardian and documented accordingly.

The biological mother of Lucas, even though she no longer has custody. Once custody is terminated, the biological parent no longer holds legal authority to make medical decisions. Unless reinstated by a court, her consent is not valid.

The child protective services caseworker assigned to Lucas. Although caseworkers play an essential role in overseeing the child's welfare, they do not typically hold the authority to sign medical consents unless explicitly granted by the court or if no other guardian is assigned. Their role is more supervisory and administrative.

EXPLANATION

✔Correct answer:

Increasing difficulty with breathing. One of the earliest and most concerning signs of fluid overload in pediatric patients is respiratory distress or increasing difficulty with breathing. Excess IV fluid can lead to pulmonary edema, especially in young children who have smaller and more sensitive cardiopulmonary systems. Fluid accumulates in the lungs, reducing gas exchange and leading to signs such as tachypnea, nasal flaring, crackles on auscultation, and increased work of breathing.

In a 3-year-old, these symptoms can escalate quickly, so early recognition is critical. Nurse Tori’s observation of breathing difficulty should prompt immediate evaluation, possible slowing or stopping of the IV infusion, and notification of the physician.

Imagine the lungs like sponges—if they get soaked with too much water (fluid), it’s harder to squeeze air in and out. That’s exactly what happens when a child is overloaded with IV fluids—they struggle to breathe because their lungs are too wet.

Nurses must vigilantly monitor fluid administration in children, as their bodies are less able to compensate for excess fluids.

• Monitor for early signs of fluid overload: increased respiratory rate, crackles, restlessness, cough, or weight gain.
• Assess intake and output closely and weigh the child daily.
• Adjust fluid rates per provider orders, especially if the child shows signs of volume excess.
• Notify the physician immediately if symptoms of respiratory distress develop.
• Ensure IV pumps are programmed correctly to prevent over-infusion.

✘Incorrect answer options:

Visible distension of the stomach. While abdominal distension can result from various issues (e.g., gas, constipation), it is not a common indicator of fluid overload. Fluid excess more directly affects the vascular and respiratory systems.

Complaints of nausea and episodes of vomiting. Nausea and vomiting can occur for many reasons (e.g., infection, medication side effects), but they are not specific signs of fluid overload.

An elevated body temperature of 102°F (38.9°C). Fever typically indicates infection or inflammation, not fluid overload. While it may coexist, it does not help directly identify fluid volume excess.

EXPLANATION

✔Correct answer:

Evaluate the child's present developmental abilities and create a customized care plan. Children with Down syndrome exhibit a wide range of cognitive and developmental abilities, and it is essential that care plans are individualized based on their actual, assessed level of functioning, not assumptions tied to chronological age or generalizations. Nurse Evans should perform a thorough developmental assessment to identify the child’s current strengths, limitations, communication style, learning capacity, and emotional needs, and then develop a care plan that reflects this unique profile.

This person-centered approach respects the nursing process (assessment, diagnosis, planning, implementation, evaluation) and aligns with the developmental approach to pediatric care, which prioritizes tailoring interventions to match where the child is developmentally—not where they “should” be chronologically.

Imagine you’re picking shoes for a child—not by their age or shoe size average, but by actually measuring their foot. That’s how care planning should work—based on what fits the individual, not the average.

Individualized care promotes optimal growth and development and supports inclusion and dignity.

• Use validated developmental screening tools to assess physical, cognitive, and social functioning.
• Collaborate with the interdisciplinary team (e.g., occupational therapists, special educators) to plan interventions.
• Involve the child in communication and learning as much as possible, using visual aids or simplified language if needed.
• Empower parents as partners in care, but also respect and include the child’s preferences and voice.
• Be sensitive to coexisting conditions common in Down syndrome (e.g., hearing loss, heart defects, speech delays) that may influence care strategies.

✘Incorrect answer options:

Design interventions based on the typical developmental milestones of a 7-year-old child. This assumes a near-typical development path and may overlook delays in areas such as speech or social interaction that are common in children with Down syndrome.

Base interventions on the developmental level of a 5-year-old, anticipating significant developmental delays. While delays are often present, assuming a fixed developmental age can lead to underestimating the child’s capabilities and potential.

Focus all educational efforts on the parents, assuming the child lacks comprehension. This approach excludes the child and diminishes their autonomy and learning potential. Many children with Down syndrome can engage in learning when information is presented in an appropriate, accessible way.

EXPLANATION

✔Correct answer:

Block the metabolic conversion of xanthine into uric acid. Allopurinol is a xanthine oxidase inhibitor used primarily to prevent hyperuricemia (elevated uric acid levels), a common complication during remission induction chemotherapy for leukemia. As chemotherapy rapidly destroys malignant white blood cells, their intracellular contents—including purines—are released into the bloodstream. These purines are metabolized into xanthine and then into uric acid via the enzyme xanthine oxidase.

Allopurinol works by inhibiting xanthine oxidase, the enzyme responsible for converting xanthine to uric acid. By blocking this metabolic step, it reduces the overall production of uric acid, thus helping to prevent complications such as tumor lysis syndrome (TLS), which can lead to acute kidney injury due to uric acid crystal deposition in renal tubules.

Imagine uric acid as dirty water that clogs your plumbing system. Allopurinol acts like a filter at the faucet, stopping the dirty water from forming in the first place—rather than trying to unclog the pipes after the damage is done.

Nurses must closely monitor for signs of tumor lysis syndrome and renal impairment in children undergoing chemotherapy.

• Monitor uric acid, blood urea nitrogen (BUN), creatinine, potassium, calcium, and phosphate levels regularly.
• Ensure the child maintains adequate hydration to support renal clearance of metabolic waste.
• Educate caregivers about the purpose of allopurinol and the importance of adherence to dosing schedules.
• Report any signs of renal impairment, such as decreased urine output, flank pain, or hematuria.
• Collaborate with the interdisciplinary team to adjust chemotherapy or supportive care as needed based on lab values.

✘Incorrect answer options:

Prevent uric acid crystals from forming in the urinary tract. While this is an indirect benefit of allopurinol, it is not the drug's primary mechanism. Allopurinol reduces uric acid levels before crystals can form, rather than directly acting on crystal formation.

Stimulate uric acid production to support urine output. This is incorrect. Allopurinol does the opposite—it reduces uric acid production. Stimulating uric acid production would increase the risk of renal damage in patients undergoing chemotherapy.

Shield the bone marrow from the side effects of chemotherapy. Allopurinol has no protective effects on bone marrow. Myelosuppression is a known adverse effect of chemotherapy, but it is managed with other strategies such as growth factors (e.g., filgrastim), not allopurinol.

EXPLANATION

✔Correct answer:

“Establish a predictable meal and snack routine with limited distractions.” For preschoolers like 4-year-old Lily, appetite fluctuations are developmentally normal, as their growth rate slows compared to infancy. However, setting a structured routine for meals and snacks creates consistency and supports healthy eating behaviors. A calm, distraction-free environment helps the child focus on eating and recognize internal hunger and satiety cues, reducing mealtime stress and improving intake over time.

This approach aligns with recommended nutritional strategies for young children, emphasizing routine, variety, and caregiver modeling. Nurse Tasha's advice should focus on creating positive mealtime experiences without pressure or bribes.

Think of meals like storytime—when it happens at the same time every day in a quiet space, the child looks forward to it and is more likely to engage. If it’s chaotic or inconsistent, it’s easy to lose interest or skip it altogether.

Educating caregivers on age-appropriate feeding strategies can reduce anxiety and support healthy growth patterns.

• Encourage scheduled meals and snacks every 2–3 hours with minimal grazing in between.
• Promote family meals where caregivers model healthy eating without pressure.
• Limit distractions like screens or toys during meals to help the child focus on food.
• Advise caregivers to offer a variety of healthy options and allow the child to choose what and how much to eat from what's offered.
• Reassure caregivers that picky eating is common and often resolves with time and consistency.

✘Incorrect answer options:

“Try giving Lily a large meal three times a day to make up for skipped meals.”  Preschoolers have small stomachs and do best with smaller, more frequent meals rather than large portions. Forcing large meals can lead to resistance and overfeeding.

“Offer Lily her favorite sweet snacks whenever she refuses to eat meals.” This teaches unhealthy eating habits and reinforces meal refusal. Offering sweets as a substitute can reduce nutrient intake and reinforce picky behavior.

“Allow Lily to skip meals entirely if she isn’t hungry, to avoid power struggles.” While pressure should be avoided, completely skipping meals removes structure. Children thrive on routine, and offering balanced meals at consistent times—even if they eat little—helps regulate appetite.

EXPLANATION

✔Correct answer:

Providing a predictable and stable daily routine. For an infant with nonorganic failure to thrive (NOFTT)—a condition often linked to psychosocial factors such as inconsistent caregiving, neglect, or emotional deprivation—emotional security and trust are key therapeutic goals. Establishing a predictable, stable daily routine supports the development of trust, promotes a sense of safety, and helps regulate feeding and sleeping patterns, all of which are essential for healthy physical and emotional development.

According to Erikson’s psychosocial stages, infants (birth to 18 months) are in the stage of “Trust vs. Mistrust.” Consistency in caregivers, schedules, and nurturing interactions helps the infant develop trust in the world. Unpredictability or chaotic routines can worsen the emotional insecurity that often underlies NOFTT.

Imagine an infant like a young seedling—it needs consistent sunlight and watering (routine and care) to grow strong. If the light and water come at random times, it weakens and wilts. Predictable care helps the infant "bloom."

Care plans for NOFTT must prioritize both nutritional and psychosocial interventions.

• Establish and maintain a consistent schedule for feeding, bathing, and sleeping.
• Minimize the number of caregivers to foster trust and attachment.
• Encourage responsive feeding—where the caregiver is emotionally present and engaged.
• Monitor growth parameters and document any changes in feeding tolerance or emotional responsiveness.
• Collaborate with interdisciplinary teams (e.g., social workers, nutritionists) for comprehensive support.

✘Incorrect answer options:

Urging the infant to self-feed by holding the bottle. At 7 months, infants may begin to grasp bottles but still need nurturing, eye contact, and caregiver interaction during feeding to support bonding. Encouraging self-feeding too early in NOFTT may further contribute to emotional detachment.

Restricting activity through strict bed rest to minimize energy use. Bed rest is not appropriate in the absence of a medical condition requiring it. Infants need opportunities for age-appropriate movement and stimulation to support developmental milestones.

Frequently switching caregivers to increase interaction. While social interaction is important, frequent changes in caregivers can disrupt attachment formation and increase stress. Infants with NOFTT need consistent, emotionally available caregivers.

EXPLANATION

✔Correct answer:

Cerebral edema. In the context of meningitis, especially bacterial meningitis, the blood-brain barrier becomes more permeable due to inflammation, increasing the risk of cerebral edema. When fluid therapy is administered—especially in high volumes or too rapidly—this can exacerbate intracranial pressure (ICP), leading to life-threatening cerebral swelling. Thus, Nurse Bennett should be particularly vigilant for signs of fluid overload resulting in cerebral edema, such as changes in level of consciousness, headache, vomiting, seizures, or papilledema.

The inflamed meninges and surrounding tissues in meningitis already predispose the brain to fluid accumulation. Overhydration can disturb the delicate fluid balance further, causing increased ICP, which can compress brain tissue, impair cerebral perfusion, and result in neurologic deterioration.

Imagine the brain like a sponge inside a rigid jar. If the sponge (brain tissue) gets swollen with too much water (fluid overload), there’s no room for expansion, and it starts pressing against the sides—leading to serious pressure buildup and damage.

Close monitoring and precise fluid management are crucial in adolescents with meningitis to prevent neurological complications.

• Monitor intake and output meticulously to avoid fluid overload.
• Assess for early signs of increased intracranial pressure (e.g., altered mental status, bradycardia, irregular respirations, hypertension—Cushing's triad).
• Evaluate neurologic status regularly using pediatric Glasgow Coma Scale.
• Administer fluids cautiously and only as prescribed, based on weight, serum electrolytes, and overall fluid balance.
• Collaborate with the healthcare provider to adjust fluid therapy if signs of cerebral edema appear.

✘Incorrect answer options:

Dehydration. While dehydration is a concern at the onset of illness or due to fever and poor intake, it is not a complication of fluid overload. In fact, the client is receiving fluids to treat or prevent dehydration.

Heart failure. Though fluid overload can precipitate heart failure in clients with pre-existing cardiac conditions, a previously healthy adolescent is unlikely to develop heart failure from typical fluid resuscitation unless massive or inappropriate volumes are administered.

Hypovolemic shock. This occurs from fluid loss, not overload. It is the opposite of the scenario described. The patient is receiving fluids, not losing them.

EXPLANATION

✔Correct answer:

Implementing droplet isolation measures. The highest-priority immediate nursing action when admitting a child with suspected or confirmed meningococcal meningitis is to initiate droplet isolation precautions. Meningococcal meningitis is caused by Neisseria meningitidis, a highly contagious bacterium transmitted via respiratory droplets. Prompt implementation of infection control measures protects healthcare personnel, other patients, and visitors from exposure.

According to CDC and hospital guidelines, droplet precautions should be initiated as soon as meningococcal infection is suspected, and maintained until the patient has received at least 24 hours of effective antibiotic therapy. This involves placing the infant in a private room, ensuring all staff wear surgical masks within 3 feet of the patient, and educating the family on proper hygiene and PPE.

Imagine meningococcal meningitis like glitter on someone’s breath—it can spread quickly and stick to anyone nearby. Isolation precautions act like a shield to keep the glitter from getting on everyone else.

Prioritizing infection control is a standard of safe pediatric nursing care in communicable diseases.

• Place the infant in a private room and initiate droplet precautions immediately upon admission.
• Ensure all staff and visitors wear surgical masks when within close proximity of the infant.
• Coordinate with infection control for proper signage and PPE use at the room entrance.
• Continue droplet precautions until 24 hours after antibiotic initiation, as per facility protocol.
• Educate parents about the importance of isolation to reduce transmission risk.

✘Incorrect answer options:

Administering acetaminophen (Tylenol). While fever management is important in meningitis, reducing transmission risk takes precedence. Acetaminophen may help with comfort, but it is not an immediate safety priority.

Gathering the infant's medical history from the parents. Obtaining history is necessary for ongoing care, but it should not delay the implementation of transmission precautions. Protecting others from infection comes first.

Familiarizing the parents with the pediatric unit's layout and routines. This is part of admission orientation and helps with family-centered care, but it is not urgent. Safety measures must be established before general orientation.

EXPLANATION

✔Correct answer:

Engages in cooperative play and enjoys following rules in games. At around 6 years of age, children transition into what is known as cooperative play, where they actively engage with peers in shared activities that involve roles, rules, and teamwork. This shift is a hallmark of the school-age developmental period and supports both cognitive and social-emotional growth. Additionally, many children at this age begin to show a genuine interest in rules and enjoy playing games that have structure and fair play—this reflects their increasing moral development and desire to function within a social group.

According to Erikson’s Industry vs. Inferiority stage, children between the ages of 6 and 12 are driven to develop competence and feel industrious by successfully navigating social and academic challenges. Enjoying rules in games allows them to explore fairness, cooperation, and the importance of mutual respect—all key elements in building self-esteem and social relationships.

Imagine a 6-year-old as a new team player on a little league team—they're excited to play by the rules, follow the coach’s guidance, and contribute to the group. It’s not just about playing; it’s about playing together and playing fair.

Nurses can empower parents by preparing them for this developmental shift and encouraging appropriate social and play opportunities.

• Encourage parents to provide opportunities for cooperative play (e.g., board games, team sports, group storytelling).
• Support the child's need for structure by establishing consistent routines and rules at home and school.
• Promote activities that involve turn-taking, sharing, and rule-following to reinforce social development.
• Reassure parents that interest in fairness and rule-following is typical and beneficial for moral reasoning.
• Facilitate early detection of social delays if a child avoids interaction or consistently struggles with peer relationships.

✘Incorrect answer options:

Shows strong separation anxiety when away from parents. While mild anxiety may still be present in some children, strong separation anxiety typically peaks during the toddler to preschool years (around 1 to 3 years old). By age 6, most children are more comfortable being away from parents, especially when engaged in school activities.

Demonstrates parallel play alongside, rather than with, peers. Parallel play is characteristic of toddlers (ages 2–3). At 6 years old, children move beyond parallel play into cooperative play, actively engaging with others through shared goals and group dynamics.

Has limited interest in the opinions or approval of others. Quite the opposite is true—children in this stage are often eager to gain the approval of parents, teachers, and peers. They begin to internalize social norms and often seek validation through their behavior and accomplishments.

EXPLANATION

✔Correct answer:

Allow the infant to go without a diaper during sleep time. The most effective way to treat a diaper rash is to reduce moisture and friction in the diaper area. Allowing the baby to go without a diaper for short periods, especially during naps or supervised sleep, gives the skin a chance to breathe and remain dry, which promotes faster healing. This practice minimizes exposure to urine and stool, both of which contribute to skin irritation and breakdown.

This approach is part of a broader strategy known as "diaper-free time," which has been shown to reduce the severity and duration of diaper dermatitis by encouraging a dry and clean environment.

Think of diaper rash like a blister from wet shoes. If you keep wearing the wet shoes (a wet diaper), the blister worsens. Taking off the shoes (going diaper-free) lets the skin breathe and heal.

Nurses should provide evidence-based strategies to caregivers managing common infant skin issues like diaper rash.

• Encourage diaper-free time during the day, especially when the infant can be supervised on an absorbent surface.
• Cleanse the area gently with warm water and soft cloth—avoid alcohol-containing wipes if irritation is present.
• Apply a thick barrier cream (e.g., zinc oxide) to protect the skin from moisture and irritants.
• Change diapers frequently to prevent prolonged moisture exposure.
• Educate caregivers to monitor for signs of secondary infection (e.g., spreading rash, pus, fever) and seek medical care if needed.

✘Incorrect answer options:

Use cloth diapers temporarily until the rash clears. While cloth diapers allow more airflow than some disposables, they may not offer the same moisture-wicking benefits. Also, frequent washing and use of detergent residues can irritate sensitive skin. The focus should be on keeping the area dry, clean, and protected.

Continue wiping with baby wipes at every diaper change. Many baby wipes contain alcohol, fragrances, or preservatives that can worsen irritation, especially during active diaper rash. It's best to use plain water and a soft cloth or hypoallergenic, alcohol-free wipes.

Increase fluid intake to help clear the rash. Diaper rash is not caused by dehydration or lack of fluid. Increasing fluids won’t address the underlying skin irritation and might lead to more frequent urination, potentially worsening the rash if diaper changes aren't also increased.

EXPLANATION

✔Correct answer:

Recording all nursing care and interventions performed during her shift. The most critical task Nurse Clara must complete before ending her shift is documenting all nursing care and interventions performed. Accurate, timely, and comprehensive documentation ensures continuity of care, legal protection, and supports safe communication during shift handoff. Incomplete or delayed documentation can result in missed care, errors, or compromised patient safety, particularly in the pediatric setting where detailed observation is essential.

In pediatric care, documentation includes vital signs, medication administration, pain assessments, growth and developmental observations, and responses to treatments. This information is essential for the incoming nurse to make informed decisions and to maintain the integrity of the healthcare record.

Think of your documentation like handing off the baton in a relay race. If you forget to pass it properly, the next runner can’t continue the race safely or effectively.

Completing documentation before shift change is a key professional responsibility and a critical aspect of safe nursing practice.

• Ensure all charting is accurate, objective, and time-stamped before the end of the shift.
• Document all assessments, medications given, treatments performed, and any communication with families or physicians.
• Include any changes in condition, behavioral observations, and patient/family education provided.
• Use standardized nursing language and comply with institutional and legal documentation standards.
• Support a thorough and effective handoff report by referencing completed documentation.

✘Incorrect answer options:

Replacing linens on the pediatric clients’ beds. While clean linens contribute to patient comfort, this task is non-urgent and can be delegated or addressed by the next shift if time is limited. It does not impact continuity of care as directly as documentation does.

Refilling bedside supplies needed for dressing changes during the next shift. This is helpful for workflow, but it is a supportive task, not a critical nursing responsibility that directly affects patient safety or legal accountability.

Disposing of room trash before leaving for the day. Maintaining cleanliness is important, but like the above, this is a lower-priority environmental task that does not carry the same clinical or legal importance as accurate charting.

EXPLANATION

✔Correct answer:

At 12 months of age. Lead poisoning screening is routinely recommended at 12 months of age, particularly for children who are at increased risk due to environmental exposures, such as living in older housing with lead-based paint or in communities with known lead contamination. This timing aligns with the child’s increased mobility and exploratory behavior, including frequent hand-to-mouth activity, which heightens their risk of ingesting lead from contaminated surfaces or dust.

Lead poisoning in children is often asymptomatic in the early stages but can result in irreversible neurological and developmental damage if not detected early. The CDC and American Academy of Pediatrics recommend targeted or universal screening based on regional risk. The most commonly used test is a capillary blood lead level (BLL) test, followed by a confirmatory venous test if levels are elevated.

Think of lead exposure like a slow, silent leak in a boat—if not found early, it can cause long-term damage below the surface. Screening at 12 months is like checking the hull before serious problems develop.

Nurses play an essential role in both screening and educating families about lead poisoning prevention.

• Administer or arrange for a blood lead level screening at the 12-month wellness visit.
• Identify environmental risk factors, such as peeling paint in pre-1978 homes, imported toys, or contaminated water pipes.
• Educate caregivers about proper handwashing, nutrition (adequate iron and calcium intake can reduce lead absorption), and keeping play areas clean.
• Coordinate follow-up testing or referrals for environmental assessment if BLL is elevated.
• Document findings and communicate results with the primary care provider and public health authorities if required.

✘Incorrect answer options:

At 6 months of age. Routine lead screening is not typically recommended at 6 months unless there are known, high-risk exposures. At this age, infants are less mobile and less likely to ingest environmental lead.

At 18 months of age. While some children may receive follow-up testing at this time (especially if previous results were elevated), initial screening should begin at 12 months, not delayed until 18 months.

At 2 years of age. This is the second recommended screening point, especially for children at continued risk. However, it is not the starting point for lead screening—it should begin at 12 months.

EXPLANATION

✔Correct answer:

Use a blow-dryer on a cool setting to blow air under the cast. Intense itching under a cast is a common complaint, particularly in adolescents who may be more likely to attempt unsafe self-remedies. The safest and most appropriate nursing intervention is to use a blow-dryer on a cool setting to circulate air under the cast. This method can help soothe the itch without introducing moisture, foreign objects, or compromising skin integrity.

This strategy avoids damaging the skin or the cast itself, and it reduces the risk of skin breakdown, infection, or pressure sores, which can occur when items are inserted inside the cast or when the skin remains damp.

If something is irritating inside a sealed container, blowing air inside cools and relieves discomfort—without needing to open or poke into it. Similarly, blowing cool air into a cast relieves the itch without causing damage.

Education on cast care and safe symptom relief is essential to prevent complications during recovery.

• Instruct the patient never to insert any object into the cast, as it can break the skin and lead to infection.
• Recommend blowing cool air into the cast for relief from itching.
• Advise against using water or lotions, which can become trapped and irritate the skin.
• Regularly assess for signs of impaired circulation or infection (e.g., foul odor, drainage, increased pain).
• Encourage Mason to notify staff if the itching becomes severe or if there are signs of cast complications.

✘Incorrect answer options:

Gently insert sterile applicators into the cast to scratch the area. Even with sterile tools, inserting objects under the cast can injure the skin, causing abrasions or pressure sores that go unnoticed until complications arise.

Pour cool water directly under the cast. Introducing moisture beneath the cast can weaken the cast material and create a warm, moist environment conducive to skin breakdown or infection.

Use a sterile applicator to apply hydrocortisone cream beneath the cast. Creams should not be applied under a cast because they can’t evaporate properly and may trap moisture, increasing the risk of skin maceration or dermatitis.

EXPLANATION

✔Correct answer:

Ineffective airway clearance due to potential swelling. In any patient with facial and upper body burns, especially those involving the face and chest, the airway is the most immediate and life-threatening concern. Third-degree (full-thickness) burns in these regions can lead to inhalation injury, airway edema, and compromised ventilation. Swelling from thermal injury to the airway can progress rapidly and cause acute airway obstruction.

Therefore, Nurse Ava must prioritize the nursing diagnosis of ineffective airway clearance, as airway patency and adequate gas exchange are essential for survival. Immediate interventions may include airway assessment, oxygen therapy, preparation for intubation, and continuous respiratory monitoring.

Think of the airway like a tunnel. If a fire damages the tunnel’s walls, they might swell and collapse. You wouldn’t fix the lighting (infection risk or body image) before ensuring the tunnel stays open for traffic (air to pass through).

Immediate and focused respiratory management is critical in burn patients, especially those with facial burns or suspected inhalation injuries.

• Assess airway patency, voice quality, and breathing effort continuously.
• Monitor for signs of respiratory distress: hoarseness, stridor, singed nasal hairs, soot in sputum.
• Prepare for early intubation if signs of inhalation injury are present.
• Administer humidified oxygen as ordered and monitor oxygen saturation.
• Collaborate with respiratory therapy and the burn team for advanced airway management.

✘Incorrect answer options:

Disturbed body image from visible burn injuries. While body image concerns are very real in pediatric burn patients, especially with facial involvement, this is not the immediate priority. It is addressed in the long-term rehabilitation phase, not during the acute phase when survival is the main focus.

Impaired urinary elimination resulting from fluid shifts. Fluid shifts and renal function are important concerns, especially in large burns, but they come after airway management. Monitoring urinary output is part of fluid resuscitation, but it is not the first priority.

High risk for infection due to skin barrier damage. Infection is a major concern in burn care, particularly once the acute phase stabilizes. However, infection risk is secondary to airway compromise in the initial hours post-burn.

EXPLANATION

✔Correct answer:

Iron-fortified infant formula as the primary nutrition source. At 5 months of age, infants rely on breast milk or iron-fortified formula as their primary source of nutrition, providing essential nutrients including protein, fats, vitamins, and minerals crucial for growth and brain development. If breastfeeding is discontinued before 12 months, the only appropriate alternative is an iron-fortified infant formula. This type of formula is specifically designed to meet the infant's dietary needs, particularly for iron, which is essential for preventing iron-deficiency anemia—a common concern in infants after 4 months of age.

The introduction of solids typically begins around 6 months, but even then, formula or breast milk continues to be the main nutritional source until the first year.

Think of infant formula as the “full meal” for a baby. It’s like a balanced smoothie packed with everything the baby needs, while fruits, veggies, and other foods are just side snacks—not enough to carry the baby's full nutritional load at this stage.

It’s important for nurses to guide caregivers on safe and developmentally appropriate nutrition practices.

• Educate the mother that whole cow’s milk is not recommended before 12 months due to its low iron content and potential to irritate the infant's kidneys and gastrointestinal lining.
• Recommend iron-fortified infant formula as the sole milk source until the infant turns 1 year old.
• Advise that solid foods may be introduced around 6 months, but only as a supplement—not a replacement—for milk/formula.
• Discourage early introduction of juice or water, which may reduce formula intake and pose a risk of electrolyte imbalance or nutrient dilution.
• Continue monitoring growth parameters and developmental milestones to ensure nutritional adequacy.

✘Incorrect answer options:

Whole cow’s milk as a substitute for breast milk. Cow's milk is not appropriate before 12 months. It lacks sufficient iron and may contribute to iron-deficiency anemia and stress the infant’s kidneys.

Pureed fruits and vegetables as the main source of calories. At 5 months, infants are not developmentally ready to rely on solids for primary nutrition. Solids are introduced gradually around 6 months as a supplement, not a substitute.

Water and diluted juice to keep the infant hydrated. Infants under 6 months typically do not need water or juice. Breast milk or formula provides all the necessary fluids and hydration. Introducing water or juice too early can interfere with nutrient intake and lead to imbalances.

EXPLANATION

✔Correct answer:

Essential safety guidelines for the infant. At 8 months of age, infants are rapidly developing gross motor skills such as crawling, sitting unsupported, and possibly even beginning to pull to stand. These milestones greatly increase their risk of unintentional injuries. Therefore, reinforcing safety guidelines is a critical component of discharge teaching. Nurse Rodriguez must educate the parents about accident prevention strategies to protect the child in the home environment and during feeding, bathing, and play.

This age marks the onset of mobility and exploration. The infant may begin reaching for objects, placing items in the mouth (increasing the risk for choking), and exploring hazardous areas like stairs or cabinets. The most common causes of injury at this stage include falls, burns, choking, suffocation, and poisoning—many of which are preventable with anticipatory safety guidance.

Think of an 8-month-old as a tiny explorer who’s just discovered how to crawl into “new worlds”—only they don’t yet understand danger. Safety guidelines are like putting up fences around cliffs and warning signs in unfamiliar lands to keep the little explorer safe.

Nurses play a crucial role in injury prevention by providing developmentally appropriate, evidence-based safety education during discharge teaching.

• Educate caregivers on baby-proofing the home—installing safety gates, securing furniture, and locking cabinets with hazardous items.
• Warn about choking hazards—only offer age-appropriate solid foods and keep small objects out of reach.
• Emphasize never leaving the infant unattended on elevated surfaces or in bathtubs.
• Teach parents about the proper use of car seats (rear-facing, appropriately installed).
• Reinforce the importance of supervising the infant at all times, especially as mobility increases.

✘Incorrect answer options:

Information regarding nursery school options. While childcare planning is important, it is not developmentally urgent for an 8-month-old infant. Most infants this age are not yet enrolled in structured nursery school, and safety concerns take precedence at this developmental stage.

Guidance on initiating toilet training. Toilet training is not appropriate at 8 months of age. Most children are developmentally ready to begin toilet training between 18 and 24 months, when they have developed bowel and bladder control and can follow simple instructions.

Preparation protocols for potential surgical interventions. There is no indication in the scenario that the infant requires surgery. Educating parents about hypothetical surgical procedures would be irrelevant and potentially anxiety-provoking unless there is a specific medical need.

EXPLANATION

✔Correct answer:

Gown, gloves, a mask, and eye protection (goggles or face shield). Severe Acute Respiratory Syndrome (SARS) is primarily transmitted through respiratory droplets, but it can also spread via aerosols and contact with contaminated surfaces. Because of its high infectivity and potential for airborne transmission in certain healthcare settings (e.g., during aerosol-generating procedures like suctioning or intubation), airborne and droplet precautions are recommended.

Therefore, full PPE—including gown, gloves, a mask (preferably N95 or higher), and eye protection—is essential to protect healthcare workers. Eye protection is critical because mucous membranes (eyes, nose, mouth) are potential entry points for the virus. The mask prevents inhalation of infectious particles, while the gown and gloves reduce the risk of contact transmission.

Think of PPE like a raincoat outfit in a storm. If you're stepping into a storm of droplets, would you wear just gloves or a raincoat alone? No—you'd wear the full outfit: coat, boots, umbrella, and maybe even goggles if it's windy. The same logic applies with SARS—you need full coverage.

When caring for a patient with SARS or any suspected airborne infectious disease, infection control is a top priority.

• Place the patient in a negative pressure airborne isolation room (AIIR) if available.
• Use an N95 respirator or higher-level respiratory protection, especially during aerosol-generating procedures.
• Don and doff PPE using proper technique to prevent contamination.
• Practice strict hand hygiene before and after all patient contact and PPE removal.
• Limit the number of staff entering the room and ensure all staff are trained in infection control procedures.

✘Incorrect answer options:

Gloves only. Gloves protect against direct contact with bodily fluids or contaminated surfaces but offer no protection against respiratory droplets or airborne particles.

Gown and gloves. While this combination provides some contact protection, it does not protect the respiratory system or eyes—both are critical when dealing with airborne or droplet-transmitted infections like SARS.

Gown, gloves, and a mask. This is almost complete, but it omits eye protection, which is essential in preventing transmission through mucous membranes. Eye exposure to droplets can lead to infection, particularly with highly transmissible viruses like SARS.

EXPLANATION

✔Correct answer:

“Our child will have to maintain these dietary restrictions for the rest of their life.” Celiac disease is a chronic, autoimmune disorder triggered by the ingestion of gluten, a protein found in wheat, barley, and rye. Exposure to gluten causes an immune-mediated inflammatory response in the small intestine, leading to villous atrophy, malabsorption, and a range of gastrointestinal and systemic symptoms. The only effective treatment is lifelong adherence to a strict gluten-free diet. Consuming even small amounts of gluten can cause intestinal damage and symptom recurrence, even if the child is asymptomatic.

Patient and family education should emphasize that celiac disease is not outgrown and there is no cure—management depends solely on strict and permanent dietary modification.

Think of gluten as a hidden "trigger" switch. For someone with celiac disease, even a tiny push of that switch causes damage. The only way to keep it off and avoid harm is to never touch it again—ever.

Effective teaching includes educating parents on food labels, cross-contamination risks, and nutritional planning.

• Instruct caregivers to eliminate all sources of wheat, barley, and rye from the child’s diet.
• Encourage reading food labels for hidden gluten-containing ingredients like malt or modified food starch.
• Promote use of naturally gluten-free grains such as rice, corn, and quinoa.
• Discuss cross-contamination prevention at home and in shared cooking environments (e.g., separate toasters and utensils).
• Recommend consultation with a registered dietitian for individualized meal planning and nutritional support.

✘Incorrect answer options:

“We'll adhere to these guidelines until our child's symptoms resolve.”  This response indicates a misunderstanding. Symptoms may subside, but intestinal damage can continue silently if gluten is reintroduced. Lifelong dietary adherence is still required.

“Our child will need to follow these dietary restrictions until they reach adulthood.”  This implies that dietary changes are temporary. In reality, celiac disease is lifelong and requires permanent lifestyle modifications regardless of age.

“We'll follow these instructions until our child has finished growing and developing.” Growth and development are important, but gluten must still be avoided after these stages. Returning to gluten consumption would result in a relapse of the disease process.

EXPLANATION

✔Correct answer:

Past history of asthma requiring regular steroid use. A past history of asthma requiring regular steroid use is a major red flag for potential severe exacerbations. This indicates that Liam has persistent or moderate-to-severe asthma, which is more difficult to control and is associated with a higher risk for life-threatening episodes. Regular use of inhaled corticosteroids suggests chronic airway inflammation and a pattern of frequent or severe symptoms, possibly with poor baseline pulmonary function or a history of hospitalization or emergency interventions.

According to the National Asthma Education and Prevention Program (NAEPP), previous intensive therapy, especially systemic steroid use or ICU admission, is one of the most important predictors of future severe exacerbations.

If a person needs regular medication to keep their condition stable, it logically means their underlying disease is more severe. Just like needing brakes applied constantly to slow a car implies that the car tends to speed out of control—consistent steroid use means the asthma tends to worsen without tight control.

Children with a history of frequent or severe asthma episodes require more aggressive monitoring and education to prevent worsening.

• Assess the child’s current asthma action plan and medication adherence.
• Monitor for signs of worsening: increased work of breathing, use of accessory muscles, and decreased oxygen saturation.
• Educate parents about early warning signs and the importance of medication compliance, especially with corticosteroids.
• Collaborate with the interdisciplinary team to optimize long-term asthma control strategies.
• Ensure the environment is free of known asthma triggers (dust, smoke, allergens).

✘Incorrect answer options:

Oxygen saturation measured at 95%. While oxygen saturation should be monitored closely, 95% is within the normal range for a child and not immediately alarming, especially if no signs of respiratory distress are present.

Slight increase in breathing effort. Mildly increased work of breathing can be a normal response to mild asthma symptoms. It warrants observation but is not the most concerning risk factor on this list.

No visible intercostal or substernal retractions. The absence of retractions is actually a reassuring sign, suggesting that the child is not experiencing significant respiratory muscle fatigue or distress at this moment.

EXPLANATION

✔Correct answer:

The child’s individual developmental readiness. The most critical factor in successful toilet training is assessing the toddler’s developmental readiness, rather than focusing strictly on age or external expectations. While many children begin to show signs of readiness between 18 to 24 months, this can vary widely. Readiness encompasses a combination of physical, cognitive, emotional, and motor skills—such as the ability to stay dry for short periods, communicate needs, follow simple instructions, and show interest in toileting behaviors.

Starting toilet training before the child is developmentally ready often leads to frustration, resistance, and delays in progress. Nurse May should emphasize watching for specific readiness cues rather than basing timing solely on chronological age or comparisons to peers.

Think of toilet training like planting seeds. Just because it’s spring doesn’t mean every flower will bloom at the same time—each child "blooms" when they’re developmentally ready.

Nurses should guide parents on signs of readiness and create a supportive, pressure-free environment for toileting.

• Educate parents to observe signs of readiness (e.g., staying dry for 2+ hours, awareness of wet/soiled diapers, ability to pull pants down, showing interest in others’ bathroom habits).
• Encourage praise and positive reinforcement rather than punishment or pressure.
• Advise parents that regression may occur during illness, stress, or major changes (e.g., new sibling).
• Recommend a relaxed, child-led approach that avoids comparison with siblings or peers.
• Promote the use of child-friendly toilet seats or potties to build comfort and familiarity.

✘Incorrect answer options:

The importance of a consistent toilet training routine. While routine is helpful after readiness is established, it is not the most crucial initial factor. Forcing consistency before the child is ready may lead to resistance.

The mother’s optimistic and supportive mindset. A positive parental attitude certainly supports the process, but it alone cannot determine success if the child lacks readiness.

The typical developmental progress of children the same age. Every child develops at their own pace. Comparing to peers may create unrealistic expectations and unnecessary pressure.

EXPLANATION

✔Correct answer:

Rapid breathing. In cases of metabolic acidosis, such as that seen with dehydration in infants, the body attempts to compensate by increasing the respiratory rate to "blow off" excess carbon dioxide (CO₂), which is an acidic component in the blood. This respiratory compensation helps to raise blood pH toward normal by reducing the concentration of carbonic acid. This process is known as respiratory compensation via hyperventilation, and in infants, it presents as tachypnea (rapid breathing).

When hydrogen ion concentration increases due to metabolic acidosis, the respiratory center in the brainstem is stimulated. In response, the lungs increase the rate and depth of breathing—commonly referred to as Kussmaul respirations in older children and adults. In infants, this often manifests as rapid, somewhat deep breathing, although not as pronounced as in older patients.

Think of the infant’s body as trying to get rid of “extra acid fumes” (CO₂). To do that, it turns on the “vent fan” (lungs) at high speed—so the fan (breathing) works faster to push the fumes out and keep the room (body) balanced.

Accurate respiratory assessment and timely intervention are critical when managing infants with acid-base imbalances.

• Monitor respiratory rate and pattern frequently for signs of compensation or fatigue.
• Evaluate for other signs of metabolic acidosis (e.g., lethargy, poor feeding, irritability).
• Support fluid and electrolyte replacement as prescribed to correct the underlying cause.
• Ensure proper positioning to facilitate effective ventilation.
• Collaborate with the healthcare team to monitor arterial blood gases if needed.

✘Incorrect answer options:

A reduction in white blood cell count. White blood cell count changes are not a direct or primary sign of metabolic acidosis. A decrease could suggest bone marrow suppression or viral infection, but not acid-base imbalance.

A decrease in platelet count. Thrombocytopenia (low platelets) is unrelated to metabolic acidosis. Platelet levels may fluctuate due to sepsis, bone marrow issues, or certain medications—not typical in dehydration-induced metabolic acidosis.

Shallow breathing. Shallow breathing may occur with respiratory depression or fatigue, but it is not the expected compensatory response to metabolic acidosis. The body needs to increase ventilation to excrete CO₂, so breathing becomes more rapid and sometimes deeper.

EXPLANATION

✔Correct answer:

Strategies for preventing accidental injuries. For school-aged children (typically 6–12 years old), injury prevention remains a top health teaching priority due to their increased independence, mobility, and risk-taking behaviors. As children begin to explore their environments more freely—biking, climbing, playing sports, and sometimes walking to school alone—they are at greater risk for accidents and unintentional injuries, especially if safety habits are not well established.

Educational efforts at this stage should include age-appropriate safety practices such as helmet use, seatbelt safety, pedestrian rules, water safety, and supervised recreational activities. These interventions are essential for reducing morbidity and mortality in this age group.

Think of school-age kids like beginner drivers on the road of life—curious and fast-moving but not fully aware of the risks. Safety education is like giving them a GPS and seatbelt before they take off.

Anticipatory guidance from nurses can help parents proactively support their child's safety and development.

• Educate parents and children on injury prevention strategies based on the child’s activities (e.g., playground safety, bike helmets, sport-specific gear).
• Discuss supervision and setting boundaries for new freedoms (e.g., walking to a friend’s house).
• Encourage safe use of technology and online environments as children become more digitally active.
• Promote open communication about peer pressure and decision-making in potentially risky situations.
• Reinforce consistent use of protective equipment during sports or recreational play.

✘Incorrect answer options:

The use of a night light to reduce nighttime anxieties. This concern is more relevant to preschool-aged children, who commonly experience fear of the dark or separation anxiety. It is less developmentally appropriate as a teaching priority for school-aged children.

Normalizing and explaining fears related to bodily harm. Fears of bodily harm are typical for preschoolers (ages 3–5), who have active imaginations and limited understanding of body integrity. By the school-age stage, children generally understand that minor injuries are not catastrophic.

Promoting the child's independence in dressing themselves. Self-dressing is usually mastered by age 5. While encouraging autonomy remains important, this skill is already expected by the time a child enters the school-age years and does not require prioritization in health teaching.

EXPLANATION

✔Correct answer:

A growing eagerness to engage in play. For toddlers like 15-month-old Theo, play is a natural behavior that signals comfort, emotional security, and physiological well-being. After surgery, if a toddler begins to show interest in playing, it is a strong indicator that pain is well-managed or absent. At this developmental stage, play is one of the most important forms of communication. A return to play behaviors typically reflects a state of comfort, stable vital signs, and minimal pain.

Pain and discomfort in toddlers usually suppress typical behaviors such as eating, sleeping, and playing. Thus, eagerness to engage in play serves as a positive behavioral cue that the child is not in significant pain.

Think of play as a toddler’s “happy meter.” If the child is smiling, exploring toys, and interacting—chances are they’re feeling pretty good. If they’re withdrawn and quiet, something’s likely off.

Pain assessment in young children should include both behavioral observations and physiological signs, especially in non-verbal or limited-verbal populations.

• Use age-appropriate pain assessment tools, such as the FLACC scale (Face, Legs, Activity, Cry, Consolability).
• Observe for return to baseline behaviors like play, eating, and engaging with caregivers.
• Monitor physiological indicators but interpret them alongside behavioral cues for accuracy.
• Encourage play as part of the healing process and include familiar toys or comfort objects.
• Evaluate pain regularly and administer analgesics as prescribed to maintain comfort.

✘Incorrect answer options:

A noticeable drop in appetite. A reduced appetite is a common sign of discomfort, pain, or distress in toddlers. It would not suggest comfort or pain relief.

An elevated heart rate. Tachycardia is a physiological indicator of pain or stress, not comfort. Postoperative pain often manifests through elevated vital signs in young children.

Reduced urinary output. Decreased output can be a sign of dehydration, fluid imbalance, or stress response, and is not indicative of comfort or pain resolution.

EXPLANATION

✔Correct answer:

Between 48 to 72 hours post-injection. The tuberculin skin test (TST), also known as the Mantoux test, is used to identify whether an individual has been infected with Mycobacterium tuberculosis. The test involves the intradermal injection of purified protein derivative (PPD), which elicits a delayed-type hypersensitivity reaction in those previously sensitized to TB antigens.

The peak immune response occurs between 48 and 72 hours after the injection. During this time, Nurse Davis should measure the induration (not redness) at the injection site to determine whether the result is positive or negative, based on the patient's risk category and the size of the induration.

Think of the skin test like baking a cake—you can’t judge it right after putting it in the oven or even after just 20 minutes. It needs a specific amount of time to rise and cook (or react, in the case of TB), which is about 48 to 72 hours.

Nurses must understand when and how to properly interpret the TST to ensure accurate TB screening.

• Educate the patient and family about the importance of returning within 48–72 hours for accurate reading.
• Measure and document only the induration (firm swelling), not erythema.
• Use a ruler with millimeter markings to determine the size of the induration.
• Follow CDC guidelines to interpret results based on patient risk factors (e.g., ≥5 mm in high-risk, ≥10 mm in moderate risk, ≥15 mm in low risk).
• If the patient misses the 72-hour window, the test must be repeated, as results are no longer valid.

✘Incorrect answer options:

Immediately following the injection. There is no visible immune response immediately after administration. The body needs time to mount a delayed hypersensitivity reaction, so immediate assessment is not meaningful.

Within a 24-hour period. This is too soon to detect a delayed hypersensitivity response. Reading at this stage may lead to a false-negative result.

After a 5-day period. This is too late, as the reaction typically begins to subside after 72 hours. Reading after 5 days may also yield inaccurate or falsely negative results.