CPEN Pediatric Assessment 5 — Questions and Answers
Question 1: 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:
- Document the bruising and continue the survey
- Notify the physician and initiate child protective services protocol (Correct answer)
- Apply warm compresses to reduce swelling
- Reassure the parent that bruising is common in toddlers
Correct 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.
Question 2: When assessing hydration status in a 9-month-old, which finding BEST indicates severe dehydration (>10% fluid deficit)?
- Slightly decreased urine output
- Mildly dry mucous membranes
- Sunken anterior fontanelle and absent tears with mottled skin (Correct answer)
- Heart rate at the upper limit of normal
Correct 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.
Question 3: A 10-year-old is assessed using the FLACC scale and scores 8 out of 10. Which intervention is MOST appropriate FIRST?
- Reassess in 1 hour
- Administer analgesic therapy and reassess in 15–30 minutes (Correct answer)
- Apply ice only and document
- Request a psychology consult
Correct 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.
Question 4: In pediatric shock assessment, which clinical sign is the EARLIEST indicator of compensated hypovolemic shock?
- Hypotension
- Tachycardia (Correct answer)
- Bradycardia
- Absent peripheral pulses
Correct answer: Tachycardia
Tachycardia is the earliest compensatory response to hypovolemia as the body attempts to maintain cardiac output before blood pressure falls.
Question 5: Which feature of the Pediatric Assessment Triangle (PAT) is PRIMARILY evaluated by observing the child's muscle tone, interactivity, and consolability?
- Circulation to skin
- Work of breathing
- Appearance (Correct answer)
- Level of consciousness
Correct answer: Appearance
The Appearance component of the PAT includes the TICLS mnemonic: Tone, Interactivity, Consolability, Look/gaze, and Speech/cry.
Question 6: A 5-year-old presents with inspiratory stridor, a barky cough, and low-grade fever. Which condition does this presentation MOST suggest?
- Bacterial tracheitis
- Foreign body aspiration
- Croup (laryngotracheobronchitis) (Correct answer)
- Anaphylaxis
Correct 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.
Question 7: During a rapid assessment, a pediatric nurse notes that a 3-year-old has grunting respirations. Grunting PRIMARILY serves to:
- Indicate pain rather than respiratory compromise
- Increase end-expiratory pressure to prevent alveolar collapse (Correct answer)
- Expel secretions from the lower airways
- Signal upper airway obstruction above the glottis
Correct 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.
CPEN Pediatric Assessment 5
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: