1. The practical nurse (PN) is monitoring a child who is man- ifesting signs of shock after a motor vehicle collision. Which finding is most important for
... [Show More] the PN to report to the charge nurse?
a) narrowing pulse pressure
b) apprehension
c) irritability
d) thirst
2. The mother of a 9 month old male infant is concerned be- cause he cries whenever she leaves him with a sitter. What is the best response for the practical nurse (PN) to pro- vide?
a) "Have you noticed whether your baby is teething?"
b) "Crying when you leave him in a healthy sign of attach- ment."
c) "Consider taking the baby to the doctor because he may be ill."
d) "You could consider leaving the infant more often so he can adjust."
3. Which preoperative action is most important for the prac- tical nurse (PN) to imple- ment for a newborn with meningomyelocele?
Pediatrics HESI PN Review
Answer: A
Rationale:
As shock progresses, perfusion in the mi- crocirculation becomes marginal despite compensatory adjustments, and the signs of decompensated shock become pro- nounced, such as tachycardia and narrow- ing pulse pressure (A). (The difference be- tween systolic and diastolic blood pressure), which should be reported immediately. (B,C, and D) are not as significant as (A).
Answer: B Rationale:
Healthy attachment is manifested by
stranger anxiety in late infancy (B). Pain from teething expressed by the infant's cries does not occur only when the mother leaves the infant with another person (A). The PN should evaluate the infant's developmental needs (C) before suggesting the infant may be ill. An infant who manifests stranger anx- iety is best supported by the mother if the infant is left for shorter periods of time, not (D).
Answer: C Rationale:
A meningomyelocele provides a direct entry for bacteria into the central nervous system, leading to meningitis. Measures that protect
a) document vital signs
b) prevent skin breakdown
c) minimize the risk for infec- tion
d) monitor neurologic func- tioning
4. The practical nurse is car- ing for a 6 year old girl who
had surgery 12 hours ago. The child tells the PN that she does not have pain but a few min- utes later, tells her parents that she does. What child develop- ment concept is relevant to this situation?
a) inconsistency in pain re- porting suggests that pain not present
b) a child may have pain yet deny its presence to the nurse
c) truthful reporting of pain should occur by this age
d) children use pain experi- ences to manipulate their par- ents
5. A 6 year old who had a tonsil- lectomy 12 hours ago is com- plaining of thirst. What should the practical nurse (PN) offer?
a) popsicle
b) lemonade
c) orange juice
d) chocolate milk
the integrity of the meningomyelocele sac and infection control measures should be implemented to minimize the risk of infec- tion (C). (A,B, and D) should be implement- ed but do not have the priority of (C).
Answer: B Rationale:
A child may fear receiving an injection for pain or may believe that pain is a deserved punishment for some misdeed, so the pain is denied (D) when the nurse asks the child, who then readily admits having pain to a parent. This behavior should not be inter- preted as (C) but as a valid indication of pain. (A and C) are incorrect interpretations of this behavior. [Show Less]