ENPC 4th Edition: Practice Test (Graded A+ Already)
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Course
ENPC
Institution
ENPC
1. A preschooler has a small laceration that requires 2 stitches. The nurse covers the wound with a bandage knowing that it will comfort the child to have it covered. What is the developmental reason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their insi...
ENPC 4th Edition: Practice Test (Graded A+ Already)
1. A preschooler has a small laceration that requires 2 stitches. The nurse covers the wound with
a bandage knowing that it will comfort the child to have it covered. What is the developmental
reason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their insides from coming out.
B.) Preschoolers fear physical disability and believe a bandage will prevent disability.
C.) Preschoolers explore orally and will likely chew or suck on the stitches if left uncovered.
D.) Preschoolers are concerned with body image and don't want to appear different than peers.
correct answers A.) Preschoolers are magical thinkers and imagine bandages keep their insides
from coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty distinguishing
fantasy from reality. They have misconceptions about illness, injury, and bodily functions. For
example, they perceive that if their skin is cut, they fear their insides will leak out. Covering a
wound with a bandage helps them with this fear.
2. 7-month-old presents to the emergency department with a complaint of fever. Assessment
reveals a patent airway and slight cyanosis around his lips and nail beds. He is alert and
interactive. His vital signs are 38.5 C (101.3F), HR 134, RR 32, BP 78/54 mm Hg, and Spo2
84%. The nurse notes a healed surgical scar on his chest. Based on this assessment, what is the
nurse's priority?
A.) Administer ibuprofen to treat the fever.
B.) Begin oxygen via a nonrebreather mask.
C.) Obtain a surgical history.
D.) Ask if the Spo2 is normal for him. correct answers D.) Ask if the Spo2 is normal for him.
Rationale: Children with special healthcare needs may present differently than other children, but
these differences may be normal. The surgical scar on the chest is likely from a congenital heart
defect repair. The mother's chief complaint is the fever, not the color, pulse oximetry, or the
respiratory distress. This may be because these aspects of his assessment are normal. The intact
mental status is also a sign that he has adapted to lowers oxygen saturation's. The child's baseline
must come from the caregiver before any intervention.
3. An 11-year-old presents to the emergency department with a complaint of hitting his head
while playing soccer. The nurse enters the room and performs an across-the-room assessment.
He is staring at the wall. He has no increased work of breathing, and his color is pink. Using the
pediatric assessment triangle (PAT), what classification will the nurse assign?
A.) Well
Rationale: In using the PAT, there is not a Well category. A child may appear well and without
disruption in any of the three components of the PAT but is still designated sick. All pediatric
patients presenting to the emergency department are considered sick simply based on the fact
that the caregiver was concerned enough to bring the child to the emergency department (p. 54).
B.) Sick
, Rationale: If there is no disruption in any of the three components of the PAT, a pediatric patient
is considered sick. This child has an abnormality in one of the three. He is staring at the wall,
which is a disruption in the general appearance component (p. 54).
C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT. He is staring at
the wall, which is a disruption in the general appearance component. It may be that he is anxious
and fearful about the experience, but it could be a result of the head injury. More assessment is
required (p. 54).
D.) Sickest
Rationale: If there are disruptions in two or more of the three components of the PAT, a pediatric
patient is considered sickest and needs immediate evaluation and intervention. This child has an
abnormality in one of the
three components (p. 54). correct answers C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT. He is staring at
the wall, which is a disruption in the general appearance component. It may be that he is anxious
and fearful about the experience, but it could be a result of the head injury. More assessment is
required (p. 54).
4. The pediatric prioritization process components include the focused assessment, focused
history, acuity rating decision and:
A.) the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process include the pediatric
assessment triangle (PAT), the focused assessment (objective data), the focused history
(subjective data), and the assignment of the triage acuity rating. These components ensure
enough information is rapidly gathered and used to provide appropriate care and timely
interventions for pediatric patients (p. 52).
B.) developmental characteristics.
Rationale: Developmental characteristics are incorporated into each component of the pediatric
prioritization
process but do not constitute a separate element (p. 52).
C.) head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused assessment but not a separate
element (p. 52).
D.) life-saving interventions.
Rationale: Life-saving interventions should be performed at any point throughout the
prioritization process as
life threats are identified (p. 52) correct answers A.) The pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process include the pediatric
assessment triangle (PAT), the focused assessment (objective data), the focused history
(subjective data), and the assignment of the triage acuity rating. These components ensure
enough information is rapidly gathered and used to provide appropriate care and timely
interventions for pediatric patients (p. 52).
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