NCLEX-RN Exam Pack Set 2 (75 Questions & Answers Updated 2022), Exams of Nursing

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NCLEX-RN Exam Pack Set 2 (

Questions & Answers Updated

2022)

1. 1. Question

A nurse was instructed by a physician to give clarithromycin (Biaxin) for a child whose BSA is 0.55 m2. The usual adult dose is 500 mg. Biaxin is available in an oral suspension. The 100ml bottle is labeled 50 mg/ml. How many ml would the nurse give per dose? Fill in the blanks. Record your answer using one decimal place. o Answer: (3.2) mL. Correct answer: o 3.2 mL. Formula: BS A Formula: BSA Formula: Rationale: o Use the BSA formula first then the standard formula as shown above. o To get the child’s dose, multiply 0.55m2(child’s BSA) to 500 mg (usual adult dose) to get 275. o Divide 275 with 1.7 m2to get 161.76 mg. o Use the standard formula above. o Divide 161.76 mg (desired pedia dose) with 50 mg (drug on hand) and multiply by 1 ml (vehicle) to get 3.2 ml.

Computation:

 2. Question

A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first? o A. Blood sugar check o B. CT scan o C. Blood cultures o D. Arterial blood gases Correct Answer: A. Blood sugar check With a history of diabetes, the first response should be to check blood sugar levels. o Option B: Performing a CT scan at this stage of assessment is unnecessary. A computerized tomography (CT) scan combines a series of X-ray images taken from different angles around the body and uses computer processing to create cross- sectional images (slices) of the bones, blood vessels, and soft tissues inside the body. CT scan images provide more detailed information than plain X-rays do. o Option C: A blood culture test helps the doctor figure out if the client has a kind of infection that is in the bloodstream and can affect the entire body. Doctors call this a systemic infection. The test checks a sample of the blood for bacteria or yeast that might be causing the infection. o Option D: An arterial blood gas (ABG) test measures oxygen and carbon dioxide levels in the blood. It also measures the body’s acid-base (pH) level, which is usually in balance when healthy.

 3. Question

A mother is inquiring about her child’s ability to potty train. Which of the following factors is the most important aspect of toilet training? o A. The age of the child o B. The child's ability to understand instruction o C. The overall mental and physical abilities of the child o D. Frequent attempts with positive reinforcement Correct Answer: C. The overall mental and physical abilities of the child. Age is not the greatest factor in potty training. The overall mental and physical abilities of the child are the most important factor. o Option A: Readiness for toilet training varies with every age of the child. o Option B: A child who can follow simple instructions may start toilet training. However, it is not considered the most important factor. o Option D: Positive reinforcement is a great tool for toilet training, yet, it may not be the most important one.

 4. Question

A parent calls the pediatric clinic and is frantic about the bottle of cleaning fluid her child drank for 20 minutes. Which of the following is the most important instruction the nurse can give the parent? o A. This too shall pass o B. Take the child immediately to the ER o C. Contact the Poison Control Center quickly o D. Give the child syrup of ipecac

Correct Answer: C. Contact the Poison Control Center quickly. The poison control center will have an exact plan of action for this child. o Option A: Ingestion of a chemical is an emergency and should not be delayed. o Option B: Taking the client to the ER may be correct, however, they will still have to contact the Poison Control Center. o Option D: It should not be given to someone who swallowed chemicals that cause burns on contact or medicines that can cause seizures very quickly. It can be dangerous to people with some types of medical problems. When such poisoning victims got Ipecac anyway, they developed serious complications or even died.

 5. Question

A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following target areas is the most appropriate? o A. Gluteus maximus o B. Gluteus minimus o C. Vastus lateralis o D. Vastus medialis Correct Answer: C. Vastus lateralis Medications are injected into the bulkiest part of the vastus lateralis thigh muscle, which is the junction of the upper and middle thirds of this muscle. o Option A: Intramuscular injections given at the dorsogluteal and ventrogluteal sites are intended for the gluteus maximus and gluteus medius muscles, respectively. However, little research has confirmed the reliability of these sites for the presence and thickness of the target and other muscles, and subcutaneous fat.

o Option B: Never give an IM injection in the gluteal muscles to avoid the risk of sciatica nerve damage. o Option D: The vastus medialis muscle is a part of the quadriceps muscle group, located on the front of the thigh.

 6. Question

A nurse has just started her rounds delivering medication. A new patient on her rounds is a 4-year-old boy who is non-verbal. This child does not have any identification on. What should the nurse do? o A. Contact the provider o B. Ask the child to write their name on paper o C. Ask a coworker about the identification of the child o D. Ask the father who is in the room the child’s name Correct Answer: D. Ask the father who is in the room the child’s name. In this case, you can determine the name of the child by the father’s statement. You should not withhold the medication from the child after identification. o Option A: Contacting the provider is unnecessary and may take time. A pediatric patient must have folks with them inside the room, so asking the child’s folks would be the most appropriate intervention. o Option B: The child may have not yet developed his writing abilities. Some children are able to write their names at age 4, but some typically developing children still aren’t ready until well into age. o Option C: Asking a coworker would be inappropriate and against the patient’s confidentiality.

 7. Question

A patient is admitted to the hospital with a diagnosis of primary hyperparathyroidism. A nurse checking the patient’s lab results would expect which of the following changes in laboratory findings?

o A. Elevated serum calcium o B. Low serum parathyroid hormone (PTH) o C. Elevated serum vitamin D o D. Low urine calcium Correct Answer: A. Elevated serum calcium The parathyroid glands regulate the calcium level in the blood. In hyperparathyroidism, the serum calcium level will be elevated. The chronic excessive resorption of calcium from bone caused by excessive parathyroid hormone can result in osteopenia. o Option B: Parathyroid hormone levels may be high or normal but not low. The main effects of parathyroid hormone are to increase the concentration of plasma calcium by increasing the release of calcium and phosphate from bone matrix, increasing calcium reabsorption by the kidney, and increasing renal production of 1,25-dihydroxyvitamin D-3 (calcitriol), which increases intestinal absorption of calcium. o Option C: The body will lower the level of vitamin D in an attempt to lower calcium. Vitamin D levels should be measured in the evaluation of primary hyperparathyroidism. Vitamin D deficiency (a 25- hydroxyvitamin D level of less than 20 ng per milliliter) can cause secondary hyperparathyroidism, and repletion of vitamin D deficiency can help to reduce parathyroid hormone levels. o Option D: Urine calcium may be elevated, with calcium spilling over from elevated serum levels. This may cause renal stones. In addition, the chronically increased excretion of calcium in the urine can predispose to the formation of renal stones.

 8. Question

A patient with Addison’s disease asks a nurse for nutrition and diet advice. Which of the following diet modifications is not recommended? o A. A diet high in grains

o B. A diet with adequate caloric intake o C. A high protein diet o D. A restricted sodium diet Correct Answer: D. A restricted sodium diet A patient with Addison’s disease requires normal dietary sodium to prevent excess fluid loss. Patients should eat an unrestricted diet. Those with primary adrenal insufficiency (Addison disease) should have ample access to salt because of the salt-wasting that occurs if their condition is untreated. Infants with primary adrenal insufficiency often need 2-4 g of sodium chloride per day. o Option A: A well-balanced diet is the best way to keep the body healthy and to regulate sugar levels. Doctors recommend balancing protein, healthy fats, and high-quality, nutrient-dense carbohydrates. o Option B: High-calorie comfort food reduces symptoms of neuroglycopenia in Addison patients, suggesting that Addison’s disease is associated with a deficit in cerebral energy supply that can partly be alleviated by intake of palatable food. o Option C: Healthy fats and high-quality proteins slow the blood sugar rollercoaster and promote stable blood sugar levels throughout the day.

 9. Question

A patient with a history of diabetes mellitus is on the second postoperative day following cholecystectomy. She has complained of nausea and isn’t able to eat solid foods. The nurse enters the room to find the patient confused and shaky. Which of the following is the most likely explanation for the patient’s symptoms? o A. Anesthesia reaction o B. Hyperglycemia o C. Hypoglycemia o D. Diabetic ketoacidosis

Correct Answer: C. Hypoglycemia A postoperative diabetic patient who is unable to eat is likely to be suffering from hypoglycemia. Confusion and shakiness are common symptoms. Reduction in cerebral glucose availability (ie, neuroglycopenia) can manifest as confusion, difficulty with concentration, irritability, hallucinations, focal impairments (eg, hemiplegia), and, eventually, coma and death. o Option A: An anesthesia reaction would not occur on the second postoperative day. The adrenergic symptoms often precede the neuroglycopenic symptoms and, thus, provide an early warning system for the patient. Studies have shown that the primary stimulus for the release of catecholamines is the absolute level of plasma glucose; the rate of decrease of glucose is less important. o Option B: Neuropathy affects up to 50% of patients with type 1 DM, but symptomatic neuropathy is typically a late development, developing after many years of chronic prolonged hyperglycemia. Peripheral neuropathy presents as numbness and tingling in both hands and feet, in a glove-and-stocking pattern; it is bilateral, symmetric, and ascending. o Option D: Symptoms of hyperglycemia associated with diabetic ketoacidosis may include thirst, polyuria, polydipsia, and nocturia.

 10. Question

A nurse assigned to the emergency department evaluates a patient who underwent fiberoptic colonoscopy 18 hours previously. The patient reports increasing abdominal pain, fever, and chills. Which of the following conditions poses the most immediate concern? o A. Bowel perforation o B. Viral Gastroenteritis o C. Colon cancer o D. Diverticulitis

Correct Answer: A. Bowel perforation Bowel perforation is the most serious complication of fiberoptic colonoscopy. Important signs include progressive abdominal pain, fever, chills, and tachycardia, which indicate advancing peritonitis. One of the most serious complications of colonoscopy is endoscopic perforation of the colon, which has been reported as between 0.03% and 0.7%. Although colonoscopic perforation (CP) occurs rarely, it can be associated with high mortality and morbidity rates. o Option B: Viral gastroenteritis is a known cause of nausea, vomiting, diarrhea, anorexia, weight loss, and dehydration. Isolated cases can occur, but viral gastroenteritis more commonly occurs in outbreaks within close communities such as daycare centers, nursing facilities, and cruise ships. Many different viruses can lead to symptomatology, though in routine clinical practice the true causative virus is generally not identified. o Option C: If the patient is age 50 or older and at average risk of colon cancer — he has no colon cancer risk factors other than age — the doctor may recommend a colonoscopy every 10 years or sometimes sooner to screen for colon cancer. Colonoscopy is one option for colon cancer screening. o Option D: Diverticulitis may cause pain, fever, and chills, but is far less serious than perforation and peritonitis.

 11. Question

A nurse is assessing a clinic patient with a diagnosis of hepatitis A. Which of the following is the most likely route of transmission? o A. Sexual contact with an infected partner o B. Contaminated food o C. Blood transfusion o D. Illegal drug use Correct Answer: B. Contaminated food

Hepatitis A is the only type that is transmitted by the fecal-oral route through contaminated food. HAV is a single-stranded, positive-sense, linear RNA enterovirus of the Picornaviridae family. In humans, viral replication depends on hepatocyte uptake and synthesis, and assembly occurs exclusively in the liver cells. Virus acquisition results almost exclusively from ingestion (eg, fecal-oral transmission) o Option A: Hepatitis B infection, caused by the hepatitis B virus (HBV), is commonly transmitted via body fluids such as blood, semen, and vaginal secretions. [1] Consequently, sexual contact, accidental needle sticks or sharing of needles, blood transfusions, and organ transplantation are routes for HBV infection. o Option C: Before widespread screening of the blood supply in 1992, hepatitis C was also spread through blood transfusions and organ transplants. Now, the risk of transmission to recipients of blood or blood products is extremely low. o Option D: Today, most people become infected with hepatitis B, C, or D by sharing needles, syringes, or any other equipment used to prepare and inject drugs.

 12. Question

A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this? o A. A history of hepatitis C five years previously o B. Cholecystitis requiring cholecystectomy one year previously o C. Asymptomatic diverticulosis o D. Crohn's disease in remission Correct Answer: A. A history of hepatitis C five years previously Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with

hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. o Option B: Cholecystitis is the inflammation of the gallbladder. This condition does not transmit through bodily fluids. o Option C: Diverticulosis is when pockets called diverticula form in the wall of the digestive tract. The inner layer of the intestine pushes through weak spots in the outer lining. This pressure makes them bulge out, making little pouches. o Option D: Crohn’s disease is an inflammatory bowel disease. It causes inflammation of the digestive tract. This disease does not transmit through the blood.

 13. Question

A physician has diagnosed acute gastritis in a clinic patient. Which of the following medications would be contraindicated for this patient? o A. Naproxen sodium (Naprosyn) o B. Calcium carbonate o C. Clarithromycin (Biaxin) o D. Furosemide (Lasix) Correct Answer: A. Naproxen sodium (Naprosyn) Naproxen sodium is a nonsteroidal anti-inflammatory drug that can cause inflammation of the upper GI tract. For this reason, it is contraindicated in a patient with gastritis. Naproxen is used to relieve pain from various conditions such as headache, muscle aches, tendonitis, dental pain, and menstrual cramps. It also reduces pain, swelling, and joint stiffness caused by arthritis, bursitis, and gout attacks. o Option B: Calcium carbonate is used as an antacid for the relief of indigestion and is not contraindicated. Calcium carbonate is a dietary supplement used when the amount of calcium taken in the diet is not enough. Calcium is needed by the body for healthy bones, muscles, nervous system, and heart. Calcium carbonate also is used as an antacid to relieve

heartburn, acid indigestion, and upset stomach. It is available with or without a prescription. o Option C: Clarithromycin is an antibacterial often used for the treatment of Helicobacter pylori in gastritis. Clarithromycin is used to treat certain bacterial infections, such as pneumonia (a lung infection), bronchitis (infection of the tubes leading to the lungs), and infections of the ears, sinuses, skin, and throat. It also is used to treat and prevent disseminated Mycobacterium avium complex (MAC) infection [a type of lung infection that often affects people with human immunodeficiency virus (HIV)]. It is used in combination with other medications to eliminate H. pylori, a bacterium that causes ulcers. Clarithromycin is in a class of medications called macrolide antibiotics. It works by stopping the growth of bacteria. o Option D: Furosemide is a loop diuretic and is NOT contraindicated in a patient with gastritis. Furosemide is used alone or in combination with other medications to treat high blood pressure. Furosemide is used to treat edema (fluid retention; excess fluid held in body tissues) caused by various medical problems, including heart, kidney, and liver disease. Furosemide is in a class of medications called diuretics (‘water pills’). It works by causing the kidneys to get rid of unneeded water and salt from the body into the urine.

 14. Question

The nurse is conducting nutrition counseling for a patient with cholecystitis. Which of the following information is important to communicate? o A. The patient must maintain a low-calorie diet. o B. The patient must maintain a high protein/low carbohydrate diet. o C. The patient should limit sweets and sugary drinks. o D. The patient should limit fatty foods.

Correct Answer: D. The patient should limit fatty foods. Cholecystitis, inflammation of the gallbladder, is most commonly caused by the presence of gallstones, which may block bile (necessary for fat absorption) from entering the intestines. Patients should decrease dietary fat by limiting foods like fatty meats, fried foods, and creamy desserts to avoid irritation of the gallbladder. o Option A: The patient may maintain a moderate to a high-calorie diet, as a very low-calorie diet may increase the risk for gallstones that predisposes to cholecystitis. o Option B: Both animal fat and animal protein may contribute to the formation of gallstones. Vitamin C, which is abundant in plants and absent from meat affects the rate-limiting step in the catabolism of cholesterol to bile acids and is inversely related to the risk of gallstones and cholecystitis. Individuals consuming the most refined carbohydrates have a 60% greater risk for developing gallstones, compared with those who consumed the least. o Option C: Replacing sugary drinks with drinks high in fiber would reduce the risk of gallbladder stones by 15%.

 15. Question

A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit? o A. Slow, deep respirations o B. Stridor o C. Bradycardia o D. Air hunger Correct Answer: D. Air hunger Patients with pulmonary edema experience air hunger, anxiety, and agitation. Symptoms may also include coughing up blood or bloody froth; difficulty breathing when lying down (orthopnea); feeling of “air hunger” or “drowning” (this feeling is called

“paroxysmal nocturnal dyspnea” if it causes you to wake up 1 to 2 hours after falling asleep and struggle to catch your breath). o Option A: Physical findings in patients with pulmonary edema are notable for tachypnea and tachycardia. Patients may be sitting upright, they may demonstrate air hunger, and they may become agitated and confused. Patients usually appear anxious and diaphoretic. o Option B: Auscultation of the lungs usually reveals fine, crepitant rales, but rhonchi or wheezes may also be present. Rales are usually heard at the bases first; as the condition worsens, they progress to the apices. o Option C: Cardiovascular findings are usually notable for S3, accentuation of the pulmonic component of S2, and jugular venous distention. Auscultation of murmurs can help in the diagnosis of acute valvular disorders manifesting with pulmonary edema.

 16. Question

A nurse caring for several patients in the cardiac unit is told that one is scheduled for implantation of an automatic internal cardioverter-defibrillator. Which of the following patients is most likely to have this procedure? o A. A patient admitted for myocardial infarction without cardiac muscle damage. o B. A postoperative coronary bypass patient, recovering on schedule. o C. A patient with a history of ventricular tachycardia and syncopal episodes. o D. A patient with a history of atrial tachycardia and fatigue. Correct Answer: C. A patient with a history of ventricular tachycardia and syncopal episodes. An automatic internal cardioverter-defibrillator delivers an electric shock to the heart to terminate episodes of ventricular tachycardia and ventricular fibrillation. This is necessary for a

patient with significant ventricular symptoms, such as tachycardia resulting in syncope. o Option A: A patient with myocardial infarction that resolved with no permanent cardiac damage would not be a candidate. o Option B: A patient recovering well from coronary bypass would not need the device. o Option D: Atrial tachycardia is less serious and is treated conservatively with medication and cardioversion as a last resort.

 17. Question

A patient is scheduled for a magnetic resonance imaging (MRI) scan for suspected lung cancer. Which of the following is a contraindication to the study for this patient? o A. The patient is allergic to shellfish. o B. The patient has a pacemaker. o C. The patient suffers from claustrophobia. o D. The patient takes antipsychotic medication. Correct Answer: B. The patient has a pacemaker The implanted pacemaker will interfere with the magnetic fields of the MRI scanner and may be deactivated by them. Patients with cardiac implantable electronic devices or CIED are at risk for inappropriate device therapy, device heating/movement, and arrhythmia during MRI. These patients must be scheduled in a CIED blocked slot or scheduled with electrophysiology nurse or technician support. But nowadays MRI conditional cardiac implantable electronic devices are widely available. o Option A: Shellfish/iodine allergy is not a contraindication because the contrast used in MRI scanning is not iodine-based. MRI contrast agents are gadolinium chelates with different stability, viscosity, and osmolality. Gadolinium is a relatively very safe contrast; however, it rarely might cause allergic reactions in patients. o Options C: Open MRI scanners and anti-anxiety medications are available for patients with

claustrophobia. Claustrophobic patients might refuse to complete the MRI scan and need sedation. These patients need to be well informed about the MRI scan procedure. The recommendation is that a physician has a discussion with them about the details in advance. Using Larger and opener MRI systems might be helpful in claustrophobic patients. o Option D: Psychiatric medication is not a contraindication to MRI scanning. MRI helps in high- resolution investigations of soft tissues without the use of ionizing radiation. This safe modality currently becomes the imaging technique of choice for diagnosing musculoskeletal, neurologic, and cardiovascular disease. However, there are restrictions and contraindications caused by MRI magnetic fields, machine structure, and gadolinium contrast agents.

 18. Question

A nurse calls a physician with the concern that a patient has developed a pulmonary embolism. Which of the following symptoms has the nurse most likely observed? o A. The patient is somnolent with decreased response to the family. o B. The patient suddenly complains of chest pain and shortness of breath. o C. The patient has developed a wet cough and the nurse hears crackles on auscultation of the lungs. o D. The patient has a fever, chills, and loss of appetite. Correct Answer: B. The patient suddenly complains of chest pain and shortness of breath. Typical symptoms of pulmonary embolism include chest pain, shortness of breath, and severe anxiety. The physician should be notified immediately. Clinical signs and symptoms for pulmonary embolism are nonspecific; therefore, patients suspected of having pulmonary embolism—because of unexplained dyspnea, tachypnea, or chest pain or the presence of risk factors for pulmonary embolism—must undergo diagnostic tests until the

diagnosis is ascertained or eliminated or an alternative diagnosis is confirmed. o Option A: The patient may present atypical symptoms based on risk factors, such as delirium or a decreasing level of consciousness. o Option B: The diagnosis of pulmonary embolism should be sought actively in patients with respiratory symptoms UNEXPLAINED by an alternative diagnosis; symptoms may include productive cough and wheezing. o Option D: A patient with fever, chills, and loss of appetite may be developing pneumonia. Fever of less than 39°C (102.2ºF) may be present in 14% of patients; however, a temperature higher than 39.5°C (103.1º) F is not from a pulmonary embolism.

 19. Question

A patient comes to the emergency department with abdominal pain. Work-up reveals the presence of a rapidly enlarging abdominal aortic aneurysm. Which of the following actions should the nurse expect? o A. The patient will be admitted to the medicine unit for observation and medication. o B. The patient will be admitted to the day surgery unit for sclerotherapy. o C. The patient will be admitted to the surgical unit and resection will be scheduled. o D. The patient will be discharged home to follow-up with his cardiologist in 24 hours. Correct Answer: C. The patient will be admitted to the surgical unit and resection will be scheduled. A rapidly enlarging abdominal aortic aneurysm is at significant risk of rupture and should be resected as soon as possible. No other appropriate treatment options currently exist. o Option A: Admitting the patient for observation will be a delay and may result in the rupture of the

aneurysm. Immediate surgery is the only recommended management. o Option B: Sclerotherapy, in which a solution is injected into a vein, causing it to collapse, scar, and fade, remains the primary treatment for the small- vessel varicose disease of the lower extremities. o Option D: The patient should not be discharged because the abdominal aneurysm may rupture at any time and place the patient’s life at risk.

 20. Question

A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan? o A. Monitor for fever every 4 hours. o B. Require visitors to wear respiratory masks and protective clothing. o C. Consider transfusion of packed red blood cells. o D. Check for signs of bleeding, including examination of urine and stool for blood. Correct Answer: D. Check for signs of bleeding, including examination of urine and stool for blood. A platelet count of 25,000/microliter is severely thrombocytopenic and should prompt the initiation of bleeding precautions, including monitoring urine and stool for evidence of bleeding. o Option A: According to three retrospective case reviews of childhood leukemia (in which 75% to 100% of the cases were acute lymphoblastic leukemia), common presenting signs and symptoms include fever (17% to 77%), lethargy (12% to 39%), and bleeding (10% to 45%). o Option B: Requiring protective clothing is indicated to prevent infection if white blood cells are decreased. Protective garments consisting of gloves,

chemotherapy gowns, eye protection e.g.; goggles, N95 respirator, and shoe covers will be worn according to the task being performed with a Chemotherapy/Biotherapy agent or excreta of a patient who has received a Chemotherapy/Biotherapy agent within the last 48 hours. o Option C: Transfusion of red cells is indicated for severe anemia. Blood transfusions represent one of the most important forms of supportive care for patients with leukemia. Cancer is the major cause of transfusion. One-third of transfused patients have a malignant disease, with acute leukemia being the malignancy in a large part of them.

 21. Question

A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern? o A. Bulging anterior fontanel o B. Repeated vomiting o C. Signs of sleepiness at 10 PM o D. Inability to read short words from a distance of 18 inches Correct Answer: B. Repeated vomiting Increased pressure caused by bleeding or swelling within the skull can damage delicate brain tissue and may become life- threatening. Repeated vomiting can be an early sign of pressure as the vomiting center within the medulla is stimulated. o Option A: The anterior fontanel is closed in a 4-year- old child. The average closure time of the anterior fontanelle ranges from 13 to 24 months. Infants of African descent statically have larger fontanelles that range from 1.4 to 4.7 cm, and in terms of sex, the fontanelles of male infants will closer sooner compared to female infants.

o Option C: Evidence of sleepiness at 10 PM is normal for a four-year-old. Young toddlers have a sleep schedule supplemented by two naps a day. Toddler sleep problems are compounded by separation anxiety and a fear of missing out, which translates to stalling techniques and stubbornness at bedtime. o Option D: The average 4-year-old child cannot read yet, so this too is normal. At 4, many children just aren’t ready to sit still and focus on a book for long. Others may learn the mechanics of reading but aren’t cognitively ready to comprehend the words.

 22. Question

A nonimmunized child appears at the clinic with a visible rash. Which of the following observations indicates the child may have rubeola (measles)? o A. Small blue-white spots are visible on the oral mucosa. o B. The rash begins on the trunk and spreads outward. o C. There is low-grade fever. o D. The lesions have a "teardrop-on-a-rose-petal" appearance. Correct Answer: A. Small blue-white spots are visible on the oral mucosa. Koplik’s spots are small blue-white spots visible on the oral mucosa and are characteristic of measles infection. Near the end of the prodrome, Koplik spots (ie, bluish-gray specks or “grains of sand” on a red base) appear on the buccal mucosa opposite the second molars. The Koplik spots generally are first seen 1-2 days before the appearance of the rash and last until 2 days after the rash appears. This enanthem begins to slough as the rash appears. Although this is the pathognomonic enanthem of measles, its absence does not exclude the diagnosis. o Option B: The body rash typically begins on the face and travels downward. Blanching, erythematous macules and papules begin on the face at the hairline, on the sides of the neck, and behind the ears (see the

images below). Within 48 hours, they coalesce into patches and plaques that spread cephalocaudally to the trunk and extremities, including the palms and soles, while beginning to regress cephalocaudally, starting from the head and neck. Lesion density is greatest above the shoulders, where macular lesions may coalesce. The eruption may also be petechial or ecchymotic in nature. o Option C: High fever (may spike to more than 104°F) is often present. The first sign of measles is usually a high fever (often >104o F [40o C]) that typically lasts 4-7 days. This prodromal phase is marked by malaise, fever, anorexia, and the classic triad of conjunctivitis (see the image below), cough, and coryza (the “3 Cs”). o Option D: “Teardrop on a rose petal” refers to the lesions found in varicella (chickenpox). The characteristic chickenpox vesicle, surrounded by an erythematous halo, is described as a dewdrop on a rose petal

 23. Question

A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct? o A. Scarlet fever is caused by infection with group A Streptococcus bacteria. o B. "Strawberry tongue" is a characteristic sign. o C. Petechiae occur on the soft palate. o D. The pharynx is red and swollen. Correct Answer: C. Petechiae occur on the soft palate. Petechiae on the soft palate is characteristic of rubella infection. o Option A: Bacteria called group A Streptococcus or group A strep cause scarlet fever. The bacteria sometimes make a poison (toxin), which causes a rash- the “scarlet” of scarlet fever. As the name “scarlet fever” implies, an erythematous eruption is associated with a febrile illness. The circulating toxin, produced by GABHS and often referred to as

erythemogenic or erythrogenic toxin, causes the pathognomonic rash as a consequence of local production of inflammatory mediators and alteration of the cutaneous cytokine milieu. This results in a sparse inflammatory response and dilatation of blood vessels, leading to the characteristic scarlet color of the rash. o Option B: The tongue may have a “strawberry”-like (red and bumpy) appearance, which is a characteristic sign of scarlet fever. On day 1 or 2, the tongue is heavily coated with a white membrane through which edematous red papillae protrude (classic appearance of white strawberry tongue). By day 4 or 5, the white membrane sloughs off, revealing a shiny red tongue with prominent papillae (red strawberry tongue). Red, edematous, exudative tonsils are typically observed if the infection originates in this area. o Option D: The throat and tonsils may be very red and sore with scarlet fever, and swallowing may be painful. The mucous membranes usually are bright red and scattered petechiae and small red papular lesions on the soft palate are often present.

 24. Question

A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose? o A. It is the correct dose o B. The dose is too low o C. The dose is too high o D. The dose should be increased or decreased, depending on the symptoms Correct Answer: B. The dose is too low This child weighs 30 kg, and the pediatric dose of diphenhydramine is 5 mg/kg/day (5 X 30 = 150/day). Therefore,

the correct dose is 150 mg/day. Divided into 3 doses per day, the child should receive 50 mg 3 times a day rather than 25 mg 3 times a day. Dosage should not be titrated based on symptoms without consulting a physician. o Option A: Diphenhydramine is used to relieve red, irritated, itchy, watery eyes; sneezing; and runny nose caused by hay fever, allergies, or the common cold. Diphenhydramine is also used to relieve coughs caused by minor throat or airway irritation. o Option C: Diphenhydramine comes as a tablet, a rapidly disintegrating (dissolving) tablet, a capsule, a liquid-filled capsule, a dissolving strip, powder, and a liquid to take by mouth. When diphenhydramine is used for the relief of allergies, cold, and cough symptoms, it is usually taken every 4 to 6 hours. o Option D: Before you give a diphenhydramine product to a child, check the package label to find out how much medication the child should receive. Give the dose that matches the child’s age on the chart. Ask the child’s doctor if you don’t know how much medication to give the child.

 25. Question

The mother of a 2-month-old infant brings the child to the clinic for a well-baby check. She is concerned because she feels only one testis in the scrotal sac. Which of the following statements about the undescended testis is the most accurate? o A. Normally, the testes are descended by birth. o B. The infant will likely require surgical intervention. o C. The infant probably has only one testis. o D. Normally, the testes descend by one year of age. Correct Answer: D. Normally, the testes descend by one year of age. Normally, the testes descend by one year of age. In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is

stimulated. The exam should be done in a warm room with warm hands. It is most likely that both testes are present and will descend by a year. If not, a full assessment will determine the appropriate treatment. o Option A: The testes usually descend by one year of age. Most of the time, a boy’s testicles descend by the time he is 9 months old. Undescended testicles are common in infants who are born early. The problem occurs less in full-term infants. o Option B: Surgical intervention is unnecessary; the testes descend by one year of age. The testicles will descend normally at puberty and surgery is not needed. Testicles that do not naturally descend into the scrotum are considered abnormal. An undescended testicle is more likely to develop cancer, even if it is brought into the scrotum with surgery. Cancer is also more likely in the other testicle. o Option C: In young infants, it is common for the testes to retract into the inguinal canal when the environment is cold or the cremasteric reflex is stimulated.

 26. Question

A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage? o A. The tumor is less than 3 cm. in size and requires no chemotherapy. o B. The tumor did not extend beyond the kidney and was completely resected. o C. The tumor extended beyond the kidney but was completely resected. o D. The tumor has spread into the abdominal cavity and cannot be resected. Correct Answer: C. The tumor extended beyond the kidney but was completely resected.

The staging of Wilms tumor is confirmed at surgery as follows: Stage I, the tumor is limited to the kidney and completely resected; stage II, the tumor extends beyond the kidney but is completely resected; stage III, the residual non-hematogenous tumor is confined to the abdomen; stage IV, hematogenous metastasis has occurred with spread beyond the abdomen; and stage V, bilateral renal involvement is present at diagnosis. o Option A: The mass is solid at presentation and usually >10 cm. o Option B: This option describes stage 1, wherein the tumor is limited to the kidney and completely resected. o Option D: In stage IV, hematogenous metastasis has occurred with spread beyond the abdomen.

 27. Question

A teen patient is admitted to the hospital by his physician who suspects a diagnosis of acute glomerulonephritis. Which of the following findings is consistent with this diagnosis? Select all that apply. o A. Urine specific gravity of 1.040 o B. Urine output of 350 ml in 24 hours o C. Brown ("tea-colored") urine o D. Generalized edema Correct Answer: A, B, & C Acute glomerulonephritis is characterized by high urine specific gravity related to oliguria as well as dark “tea-colored” urine caused by large amounts of red blood cells. Option A: The urine is dark. Its specific gravity is greater than 1.020. RBCs and RBC casts are present. o Option B: Functional changes include proteinuria, hematuria, reduction in GFR (ie, oliguria or anuria), and active urine sediment with RBCs and RBC casts. The decreased GFR and avid distal nephron salt and water retention result in the expansion of intravascular volume, edema, and, frequently, systemic hypertension.