Comprehensive 2024 Test Bank with Detailed Rationales and Up-to-Date
Content" Ultimate ENPC Exam Preparation
2024 Comprehensive ENPC Exam Mastery (Emergency Nursing
Pediatric Course): Complete Test Bank for ENPC 6th Edition -
Essential Resource for ENPC Students' Success |
Comprehensive Review of Pediatric Emergency Nursing Care,
Including Shock Management,
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.
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.
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).
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)
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).
, 5. A 2-year-old is brought to the emergency department by her father when he found her face down in
the pool. She remains unresponsive and is breathing shallowly and slowly. Her color is pale. What is the
priority?
A.) Administer 100% oxygen
Rationale: The primary assessment in a trauma patient begins with immobilization of the cervical spine
while opening the airway. The remainder of the primary assessment interventions including oxygenation
is performed after cervical spinal immobilization (p. 64).
B.) Immobilize the cervical spine
Rationale: Any unresponsive child found in a pool must be assumed to be a trauma patient and with a
cervical spinal injury until proven otherwise. The primary assessment in a trauma patient begins with
immobilization of the cervical spine while opening the airway. The remainder of the primary
assessment interventions, including inserting an airway, oxygenation, and ventilation, is performed
after cervical spinal immobilization (p. 64).
C.) Begin bag-mask ventilation
Rationale: The primary assessment in a trauma patient begins with immobilization of the cervical spine
while opening the airway. The remainder of the primary assessment interventions, including ventilation,
is performed after cervical spinal immobilization (p. 64).
D.) Insert an oral airway
Rationale: The primary assessment in a trauma patient begins with immobilization of the cervical spine
while opening the airway. The remainder of the primary assessment interventions, including inserting an
airway, if
needed, is performed after cervical spinal immobilization (p. 64).
B.) Immobilize the cervical spine.
Rationale: Any unresponsive child found in a pool must be assumed to be a trauma patient and with a
cervical spinal injury until proven otherwise. The primary assessment in a trauma patient begins with
immobilization of the cervical spine while opening the airway. The remainder of the primary assessment
interventions, including inserting an airway, oxygenation, and ventilation, is performed after cervical
spinal immobilization (p. 64).
6. A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal alignment,
padding should be placed under which area?
