Pediatric Assessment Flashcards
7 cards from real CPEN practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Pediatric Assessment flashcards as text
During a secondary survey of a 2-year-old trauma patient, the nurse notes bruising in various stages of healing on the trunk and buttocks. The PRIORITY nursing action is:
Answer: Notify the physician and initiate child protective services protocol
Patterned or multi-stage bruising on the trunk and buttocks in a young child is a red flag for non-accidental trauma, requiring mandatory reporting per child protective services protocol.
When assessing hydration status in a 9-month-old, which finding BEST indicates severe dehydration (>10% fluid deficit)?
Answer: Sunken anterior fontanelle and absent tears with mottled skin
A sunken fontanelle, absent tears, and mottled skin together indicate severe dehydration requiring urgent fluid resuscitation.
A 10-year-old is assessed using the FLACC scale and scores 8 out of 10. Which intervention is MOST appropriate FIRST?
Answer: Administer analgesic therapy and reassess in 15–30 minutes
A FLACC score of 7–10 indicates severe pain requiring prompt analgesic administration and reassessment within 15–30 minutes to evaluate effectiveness.
In pediatric shock assessment, which clinical sign is the EARLIEST indicator of compensated hypovolemic shock?
Answer: Tachycardia
Tachycardia is the earliest compensatory response to hypovolemia as the body attempts to maintain cardiac output before blood pressure falls.
Which feature of the Pediatric Assessment Triangle (PAT) is PRIMARILY evaluated by observing the child's muscle tone, interactivity, and consolability?
Answer: Appearance
The Appearance component of the PAT includes the TICLS mnemonic: Tone, Interactivity, Consolability, Look/gaze, and Speech/cry.
A 5-year-old presents with inspiratory stridor, a barky cough, and low-grade fever. Which condition does this presentation MOST suggest?
Answer: Croup (laryngotracheobronchitis)
The classic triad of barky cough, inspiratory stridor, and low-grade fever in a preschool-age child is diagnostic of croup caused by viral laryngotracheobronchitis.
During a rapid assessment, a pediatric nurse notes that a 3-year-old has grunting respirations. Grunting PRIMARILY serves to:
Answer: Increase end-expiratory pressure to prevent alveolar collapse
Grunting is produced by partial closure of the glottis during expiration to generate intrinsic PEEP and maintain alveolar patency in conditions like pneumonia or pulmonary edema.