Peds CCRN 112 Review Questions: Critical Care Nursing for Pediatric Patients, Exams of Nursing

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Peds CCRN 112 Review Questions

The mother of a recently admitted, technology-dependent child tells the nurse that she has missed several clinic appointments. How can the nurse best help in this situation?

A. Inform the social worker about the medical neglect B. Assess the mother's access to tangible resources C. Notify the clinic physician that the child is admitted D. Reassure the mother that she is doing her best - ✔ ✔ B. Assess the mother's access to tangible resources

-The nurse's first response should be to further assess the mother's situation and determine why she has missed appointments. -Assessing tangible resources, like transportation, may better elicit the mother's needs and the nurse can then best respond from a systems thinking perspective. The nurse caring for a child who was injured in a motor vehicle crash notes positive Cullen's sign in the right abdomen around the umbilicus. This is indicative of:

A. Impending disseminated intravascular coagulopathy B. Necrotic bowel process C. Sepsis D. Intra-abdominal bleeding - ✔ ✔ D. Intra-abdominal bleeding

In cases of severe intra-abdominal bleeding, Cullen's sign (bluish discoloration around the periumbilical area) may be seen. The nurse should be concerned that the child has severe injuries and may need surgical exploration or repair. The nurse is caring for a child with liver failure and who is experiencing profound abdominal distention. What is the primary concern?

A. Renal insufficiency B. Biliary atresia C. Intestinal perforation

D. Respiratory failure - ✔ ✔ D. Respiratory failure

-Children with liver failure can experience profound abdominal ascites and distention. This process pushes up on the diaphragm and can result in respiratory distress, which can lead to respiratory failure. -Increased pressure in the abdomen can compromise perfusion to other abdominal organs, like the kidney. But in this scenario, respiratory distress is the primary concern.

A 16-year-old crashes her car into a wooden fence and is impaled through the chest by a fence post. She presents with significant shortness of breath. You are unable to auscultate breath sounds on the right side and you palpate crepitus throughout the right side of the chest. Her HR is 146 and you are unable to obtain a blood pressure. She is most likely experiencing:

A. Cardiomyopathy B. Cardiogenic shock C. Hypertensive crisis

D. Cardiogenic/obstructive shock - ✔ ✔ D. Cardiogenic/obstructive shock

-Cardiogenic/obstructive shock occurs when cardiac output is obstructed and there is an inability to provide adequate tissue perfusion despite normal intravascular volume and myocardial function. -Causes include trauma to the great vessels, tamponade, pulmonary embolism, valvular stenosis, and coarctation of the aorta A toddler who was found unresponsive in a swimming pool is in respiratory distress. On chest x-ray you see bilateral infiltrates and the PaO2/FiO2 ratio is 190. These findings suggest:

A. Aspiration pneumonia B. Viral pneumonia C. Acute respiratory distress syndrome D. Pneumothorax - ✔ ✔ C. Acute respiratory distress syndrome

• This child has signs of acute respiratory distress syndrome (ARDS), which include bilateral infiltrates on chest x-ray, PaO2/FiO2 ratio <200, and pulmonary edema, among other things.
• Both aspiration and viral pneumonia may lead to ARDS, but that's not the correct answer for this question.
• The symptoms described are not consistent with a pneumothorax. A traumatically injured 8-year-old is being cared for in the ICU. The nurse notes the child has an ICP of 18 mmHg, arterial blood pressure of 112/72 mmHg, with MAP of 86 mmHg and central venous pressure of 7 mmHg. The nurse calculates the cerebral perfusion pressure and anticipates which intervention?

A. MRI evaluation B. Ongoing monitoring C. Emergent surgery D. Fluid bolus - ✔ ✔ B. Ongoing monitoring

-This child has age-appropriate values for blood pressure, MAP, and CVP. The calculated CPP is 68 mmHg (MAP minus ICP).

-Based on the information given in this scenario, there is no indication for additional brain imaging, surgical intervention, or fluid bolus. -The nurse should continue monitoring the patient and supporting vital functions. A 4-month-old arrives with a 24-hour history of vomiting and diarrhea. The patient is lethargic, pale, cool, and clammy. Weak peripheral pulses can be palpated and her capillary refill time is

4 seconds. The child is in:

A. Hypovolemic shock B. Septic shock C. Anaphylactic shock D. Cardiogenic shock - ✔ ✔ A. Hypovolemic shock

-This patient's history and clinical exam are consistent with hypovolemic shock. -Gastroenteritis is a common cause of fluid loss in an infant, which can result in significant hypovolemia. A 5-month-old arrives unconscious with a history of falling from a changing table. Head CT reveals a subdural hematoma.

Which additional assessment finding is concerning for abusive head trauma?

A. Forehead bruising B. Poorly reactive pupils C. Retinal hemorrhage D. Linear skull fracture - ✔ ✔ C. Retinal hemorrhage

-You would not anticipate seeing retinal hemorrhage with the history provided. -You could see a bruise on the head where the baby fell, poorly reactive pupils, or a linear skull fracture. -A history that does not match the patient's injuries is concerning for inflicted trauma. A 9-month-old arrives with a burn injury. Which of these is most concerning for inflicted injury?

A. The burn injury is consistent with the history B. The parent sought out medical care immediately C. The burns have a splash pattern across the thighs

D. The parent reports the child pulled a hot pot off the stove - ✔ ✔ D. The parent reports the child pulled a hot pot off the stove

-A child this age would not have the developmental skills to pull a pot off a stove, so that statement is concerning. -Other red flags that a burn may be inflicted include linear demarcations without splash marks, and a pattern that resembles a hot object. -It is also concerning when the parent or caregiver delay seeking medical care A baby with BPD will have:

A. Left-sided heart failure B. Increased fluid requirements C. Decreased pulmonary vascular resistance D. Increased caloric needs - ✔ ✔ D. Increased caloric needs

-Infants with BPD have increased caloric needs because of the chronic increased work of breathing distress. -They require

diuretics and generally do not tolerate fluid overload. -And, they experience increased pulmonary vascular resistance and resultant right-sided heart failure. A child being treated for DKA becomes more lethargic, is difficult to arouse, and has vomited twice in the past hour. These symptoms could be interpreted as indications of:

A. Exhaustion due to lack of sleep B. The development of hypoglycemia C. Decreased intestinal motility D. Cerebral edema and increased ICP - ✔ ✔ D. Cerebral edema and increased ICP

-These symptoms are indications that the child may be developing cerebral edema and an increased ICP. -Nurses must recognize that children with DKA are at a higher risk for the development of cerebral edema and must monitor closely for any changes in neurological status. A child experiences sudden cardiac death after playing soccer. The most likely etiology is:

A. Restrictive cardiomyopathy B. Hypertrophic cardiomyopathy C. Dilated cardiomyopathy D. Kawasaki disease - ✔ ✔ B. Hypertrophic cardiomyopathy

-Hypertrophic cardiomyopathy involves thickening of the heart muscles, which can obstruct blood flow out of the left ventricle. -Intense exercise can worsen the outflow obstruction, which makes this type of cardiomyopathy the most common cause of sudden cardiac death in people younger than age 35 and in athletes. A child experiencing Diabetes Insipidus (DI) has a urine output > mL/kg/hr and a serum sodium of 158 mEq/L. The nurse should expect the patient will need:

A. Hypotonic intravenous fluids and urine output replacement B. Vasopressin administration and urine output replacement C. Hypertonic saline administration and 75% maintenance intravenous fluid

D. Vasopressin and hypertonic saline administration - ✔ ✔ B. Vasopressin and urine output replacement

-Immediate treatment for a patient with symptomatic DI is ADH replacement and urine output replacement to keep the patient from progressing to profound hypovolemic shock. -Hypotonic fluids and hypertonic saline administration are contraindicated in this situation. -Fluid restriction to 75% of maintenance needs is a treatment for SIADH. A child has just died. What's the nurse's best response to the parents?

A." You can always have other children" B. "She's in a better place now" C. "I'm so sorry for your loss" D. "It's God's will when children die". - ✔ ✔ C. "I'm so sorry for your loss"

-The loss of a child is unimaginable for parents.

-Being a quiet, supportive presence and offering a simple condolence, such as "I'm sorry," is a good initial response in this scenario. -The other options minimize the parents' emotions and do not give them a space to grieve A child having a seizure has a serum sodium level of 125 mEq/L and a decreased urine output. What disease process is most likely?

A. Diabetes mellitus (DM) B. Syndrome of inappropriate antidiuretic hormone (SIADH) C. Diabetes insipidus (DI) D. Diabetic ketoacidosis (DKA) - ✔ ✔ B. Syndrome of inappropriate antidiuretic hormone (SIADH)

-The symptoms of SIADH include hyponatremia and decreased urine output. -The child is likely having a seizure because of the low serum sodium. -A child with DI would have an increased serum sodium level and a significantly increased urine output.

-Diabetes mellitus and DKA are disorders of glucose control. A child in DKA has a glucose of 350 mg/dL. One hour later the glucose is 250 mg/dL. The nurse would anticipate the administration of:

A. Potassium chloride B. Sodium bicarbonate C. Dextrose solution D. Subcutaneous insulin - ✔ ✔ C. Dextrose solution

-As the glucose decreases to 250 mg/dL, it will become necessary to administer glucose in addition to the insulin infusion that this patient is likely already receiving. -The child in DKA will not receive SQ insulin, as she will not be able to utilize that as effectively as IV insulin. -You have no information to suggest that this patient requires electrolyte supplementation. -Sodium bicarbonate is not appropriate A child is admitted after falling off a golf cart. The child was initially awake and

alert, but now is unresponsive. The nurse should suspect which condition?

A. Hydrocephalus B. Epidural hematoma C. Subdural hematoma D. Diffuse axonal injury - ✔ ✔ B. Epidural hematoma

Epidural hematomas result from hemorrhage into the extradural space, usually from a tear in the middle meningeal artery. With the classic presentation, the child is initially awake and alert, but as the bleeding continues, the hematoma gets larger and the child can become unresponsive. A child is admitted in a hypertensive crisis and vasodilators are ordered. The nurse understands that the intention is to improve cardiac function through:

A. Increasing SVR B. Inotropic and chronotropic actions C. Decreasing afterload

D. Improving renal function - ✔ ✔ C. Decreasing afterload

-Introducing vasodilators into this child's medical management will allow for reduction of systemic vascular pressures, thereby reducing afterload. -Medications that increase SVR or have inotropic and chronotropic actions would worsen this situation. A child is admitted to the ICU following a motor vehicle collision in which he was an unrestrained passenger. He is complaining of numbness and tingling in his legs and feet, and has decreased sensation. Preliminary imaging studies are normal. The nurse anticipates:

A. Removal of the cervical collar B. Discontinuation of log rolling C. Administration of anti-anxiety medications D. Ongoing spinal cord protective measures - ✔ ✔ D. Ongoing spinal cord protective measures.

-This patient's clinical picture is consistent with spinal cord injury, even though there were no findings on imaging studies. He may

have Spinal Cord Injury Without Radiograph Abnormality (SCIWORA). -The patient should have spinal cord protective measures in place (eg, log rolling, cervical collar) at this point. A child recently underwent a diagnostic cardiac catheterization. The nurse notes the patient's distal foot is cool, with poor perfusion and an absent pulse, and should suspect what?

A. Post-procedure bleeding B. This is a normal finding C. Hematoma D. Heart failure - ✔ ✔ C. Hematoma

-Post-procedure monitoring after cardiac catheterization includes observing for bleeding and perfusion. -A hematoma can form, which may require intervention if distal perfusion is significantly compromised, and this is not a normal finding. -The assessment findings described in this question do not indicate there is bleeding or heart failure.

A child with a closed head injury has developed SIADH. Which of the following laboratory results would this patient exhibit?

A. Serum Na+ 122 mEg/L; serum Osm 262 mOsm/L B. Serum Na+ 134 mEq/L; serum Osm 280 mOsm/L C. Serum Na+ 144 mEq/L; serum Osm 282 mOsm/L D. Serum Na+ 158 mEq/L; serum Osm 295 mOsm/L - ✔ ✔ A. Serum Na+ 122 mEq/L; serum Osm 262 mOsm/L

-You know that patients with SIADH have hyponatremia and hypo-osmolality, you know that answer "A" is the best response. A critically ill patient is hypotensive with pale, mottled, and cool extremities. The nurse should be concerned for:

A. Skin failure B. Bacterial colonization C. Over hydration

D. Dehydration - ✔ ✔ A. Skin failure

-Skin failure can occur when blood is shunted away from the skin to other vital organs in a critically ill patient. -It is also associated with impaired temperature control and metabolic conditions. -Skin failure and the injuries it causes may not be preventable. A family of Middle Eastern descent requests that no male caregivers enter the room when the mother is there alone at night. What's the best response?

A. Notify the social worker that the family is interfering with care B. Assign male caregivers if necessary to meet the unit's staffing needs C. Transfer the patient to a larger intensive care unit D. Document the request and include the information in the handoff report - ✔ ✔ D. Document the request and include the information in the handoff report

-An appropriate response to diversity is to honor this family's request. -Of the options listed, documenting and including the information in the handoff report is the best way to communicate the request. -It would be important for the nurse to talk with the family about emergency scenarios where it might not be possible to honor this while still meeting the urgent needs of the child. -A plan for this scenario could then be articulated with the family's agreement. A large pediatric/adult hospital is implementing a new continuous renal replacement therapy. Crucial considerations in the process include identifying equipment, financial resources and:

A. Key stakeholders B. Staff educators C. Appropriate patients D. Attending physicians - ✔ ✔ A. Key stakeholders

-From a systems thinking perspective, key stakeholder identification is vital in the early stages of a major planned change.

-Stakeholders from both pediatric and adult areas may include nurses, physicians, educators, and others who will be impacted by the change. Decision- making and planning should include everyone's input. A nasogastric tube should not be inserted in the child with which injury?

A. Linear skull fracture B. Basilar skull fracture C. Depressed skull fracture D. Diffuse axonal injury - ✔ ✔ B. Basilar skull fracture

-Nasogastric tubes should not be inserted in patients with suspected basilar skull fractures because the tube could go up through the fracture into the brain. -These patients need an orogastric tube placed through the mouth A neonate is receiving an infusion of prostaglandin to keep the patent ductus arteriosus from closing. Which is a potential complication of this medication?

A. Seizures B. Apnea C. Rash D. Fever - ✔ ✔ B. Apnea

-Babies receiving prostaglandin are at risk for developing apnea. -Seizures, rash and fever are not significant concerns with this medication. A nurse expresses concern about the high dosage of opioids ordered for the comfort care of a terminally ill and unconscious adolescent. The family's plan is to allow a natural death after extubation, and the nurse is concerned the medications will hasten that. What is the best resource to utilize in this situation?

A. Ethics committee B. Hospital chaplain C. Risk manager D. Patient safety advocate - ✔ ✔ A. Ethics committee

-The nurse may be experiencing moral distress in this situation. Of the options listed, the ethics committee is the best resource to clarify the concept of double effect, where a legitimate act, such as relieving pain at the end of life, causes an undesired effect, such as oversedation or a slightly shortened life. -It is ethically acceptable in this situation to use higher than normal dosages of pain and anxiety relieving medications. A nurse manager feels that the number of blood culture samples reported by the laboratory as "contaminated" is excessive. The most appropriate action for the nurse manager would be to:

A. Observe the staff as they obtain blood culture samples B. Track the actual blood culture contamination rate C. Convene a staff meeting to discuss the problem D. Develop a poster demonstrating the correct procedure - ✔ ✔ B. Track the actual blood culture contamination rate

-The first step of analyzing a potential problem is to collect actual data to determine whether or not the problem truly exists. -In this scenario, the blood culture contamination rate would be determined by evaluating the number of blood cultures drawn as compared to the number that are reported as contaminated.

-Once that assessment is done, appropriate next steps such as direct observations or education can be determined. A patient is admitted with status epilepticus. After arrival, the SpO2 decreases to 85%. The priority response is:

A. Oxygen administration B. Anticonvulsant administration C. Intubation D. Bite block insertion - ✔ ✔ A. Oxygen administration

Hypoxia is a complication of seizures, and the therapeutic priority in the management of a seizure is to maintain oxygenation and ventilation. A patient presents with agitation, nuchal rigidity, and a positive Brudzinski sign. The priority intervention is:

A. ICP monitoring B. Medical restraints C. Antibiotic administration D. Intraventricular catheter - ✔ ✔ C. Antibiotic administration

-This patient is demonstrating signs of meningitis. Initial treatment includes antibiotic administration. -ICP monitoring and placement of an intraventricular catheter are not indicated in this scenario. -Restraints may be needed, but they could further agitation. A patient with a newly diagnosed condition is being discharged. The mother goes to the pharmacy to pick up the child's medications and returns to the unit without them after being told the insurance provider doesn't cover them. What is the nurse's best response?

A. Tell the mother to follow up with the primary care provider B. Obtain today's doses of the medication and give to the mother C. Notify the social worker or case manager of the situation D. Suggest the mother return to the pharmacy and pay in cash - ✔ ✔ C. Notify the social worker or case manager of the situation

-The unit's social worker or case manager should have the expertise to ensure the patient has what is needed to manage care at home, including prescription medications. -In this scenario, the nurse's best response is to seek assistance from those who can help the family navigate the system. A patient with a subclavian central venous catheter develops facial swelling, headache, dyspnea, and jugular vein fullness. The nurse suspects the patient has:

A. Deep vein thrombosis B. Pulmonary embolism C. Superior vena cava syndrome D. Catheter infection - ✔ ✔ C. Superior vena cava syndrome

-The main problem in superior vena cava syndrome is impaired return of venous blood from drainage areas like the head and neck, upper extremities, and upper thorax because of some sort of obstruction (In this case, a central venous catheter obstruction) -Symptoms occur due to back-up of blood and include facial swelling, dyspnea, cough, arm edema, and headache, full jugular veins, and engorgement of collateral veins.