CPEN Pediatric Assessment 5

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:

Accepted Answer

Notify the physician and initiate child protective services protocol

Answer

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)?

Accepted Answer

Sunken anterior fontanelle and absent tears with mottled skin

Answer

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?

Accepted Answer

Administer analgesic therapy and reassess in 15–30 minutes

Answer

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?

Accepted Answer

Tachycardia

Answer

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?

Accepted Answer

Appearance

Answer

The Appearance component of the PAT includes the TICLS mnemonic: Tone, Interactivity, Consolability, Look/gaze, and Speech/cry.

CPEN - Certified Pediatric Emergency Nurse Practice Test

CPEN - Certified Pediatric Emergency Nurse Practice Test

CPEN Pediatric Assessment 5