NCLEX Questions On Pediatric Nursing

1.

Dustin who was diagnosed with Hirschsprung’s disease has a fever and watery explosive diarrhea. Which of the following would Nurse Joyce do first?

A.

Administer an antidiarrheal
B.

Notify the physician immediately
C.

Monitor the child every 30 minutes.
D.

Nothing (These findings are common in Hirschsprung’s disease)

Correct Answer
B. Notify the pHysician immediately

Explanation
For the child with Hirschsprung’s disease. fever and explosive diarrhea indicate enterocolitis. a life-threatening situation. Therefore. the physician should be notified directly.Option A: Generally. because of the intestinal obstruction and inadequate propulsive intestinal movement. antidiarrheals are not used to treat Hirschsprung’s disease.Option C: The child is acutely ill and requires intervention. with monitoring more frequently than every 30 minutes.Option D: Hirschsprung’s disease typically presents with chronic constipation.

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2.

Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note which of the following?

A.

“Currant jelly” stools
B.

Regurgitation
C.

Steatorrhea
D.

Projectile vomiting

Correct Answer
D. Projectile vomiting

Explanation
Projectile vomiting is a key sign of pyloric stenosis.Option B: Regurgitation is seen more commonly with gastroesophageal reflux.Option C: Steatorrhea occurs in malabsorption disorders such as celiac disease.Option A: “Currant jelly” stools are characteristic of intussusception.

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3.

An 11-year-old girl with celiac disease was discharged from the hospital. An appropriate teaching was carried out by the nurse if the parents are aware of avoiding which of the following?

A.

Chicken
B.

Wheat
C.

Milk
D.

Rice

Correct Answer
B. Wheat

Explanation
Children with celiac disease cannot tolerate or digest gluten. Therefore. because of its gluten content. wheat and wheat-containing products must be avoided.Option A.C.D: Rice. milk. and chicken do not contain gluten and need not be avoided.

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4.

Which of the following applies to the defect emerging from residual peritoneal fluid confined within the lower segment of the processus vaginalis?

A.

Inguinal hernia
B.

Incarcerated hernia
C.

Communicating hydrocele
D.

Noncommunicating hydrocele

Correct Answer
D. Noncommunicating hydrocele

Explanation
With a noncommunicating hydrocele. most commonly seen at birth. residual peritoneal fluid is trapped within lower segment of the processus vaginalis (the tunica vaginalis). There is no communication with the peritoneal cavity and the fluid usually is absorbed during the first months after birth.Option A: An inguinal hernia arises from the incomplete closure of the processus vaginalis leading to the descent of an intestinal portion.Option B: Incarceration occurs when the hernia becomes tightly caught in the hernia sac.Option C: A communicating hydrocele usually is associated with an inguinal hernia because the processus vaginalis remains open from the scrotum to the abdominal cavity.

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5.

Baby Jonathan was born with cleft lip (CL); Nurse Barbara would be alert that which of the following will most likely be compromised?

A.

GI function
B.

Locomotion
C.

Sucking ability
D.

Respiratory status

Correct Answer
C. Sucking ability

Explanation
Because of the defect. the child will be unable to form mouth adequately around the nipple. thereby requiring special devices to allow for feeding and sucking gratification.Option A: GI functioning is not compromised in the child with a CL.Option B: Locomotion would be a problem for older infant because of the use of restraints.Option D: Respiratory status may be compromised if the child is fed improperly during post-operative period.

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6.

Will is being assessed by Nurse Lucas for possible intussusception; which of the following would be least likely to provide valuable information?

A.

Abdominal palpation
B.

Family history
C.

Pain pattern
D.

Stool inspection

Correct Answer
B. Family history

Explanation
Because intussusception is not believed to have familial tendency. obtaining a family history would provide the least amount of information.Option A.C.D: Stool inspection. pain pattern. and abdominal palpation would reveal possible indicators of intussusception. “Currant jelly” stools. containing blood and mucus. are an indication of intussusception. Acute. episodic abdominal pain is characteristic of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

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7.

Mr. and Ms. Byers’ child failed to pass meconium within the first 24 hours after birth; this may indicate which of the following?

A.

Celiac disease
B.

Intussusception
C.

Hirschsprung’s disease
D.

Abdominal-wall defect

Correct Answer
C. Hirschsprung’s disease

Explanation
Failure to pass meconium within the first 24 hours after birth may be a sign of Hirschsprung’s disease. a congenital anomaly resulting in mechanical obstruction due to weak motility in an intestinal segment.Option A.B.D: Failure to pass meconium is not connected with celiac disease. intussusception. or abdominal-wall defect.

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8.

Which of the following parameters would Nurse Max monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageL REFLUX (GER)?

A.

Urine
B.

Vomiting
C.

Weight
D.

Stools

Correct Answer
B. Vomiting

Explanation
Thickened feedings are used with GERto stop the vomiting. Therefore. the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings.Option A.D: No relationship exists between feedings and characteristics of stools and urine.Option C: If feedings are ineffective. this should be noted before there is any change in the child’s weight.

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9.

Baby Ellie is diagnosed with gastroesophageal reflux (GER); which of the following nursing diagnoses would be inappropriate?

A.

Risk for aspiration
B.

Impaired oral mucous membrane
C.

Deficient fluid volume
D.

Imbalanced nutrition: Less than body requirements

Correct Answer
B. Impaired oral mucous membrane

Explanation
GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower-esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.Option A.C.D: Fluid volume deficit. risk for aspiration. and imbalanced nutrition are appropriate nursing diagnoses.

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10.

Steve is diagnosed with celiac disease and experiences celiac crisis secondary to upper respiratory tract infection; which of the following would Nurse Nancy expect to assess?

A.

Lethargy
B.

Weight gain
C.

Respiratory distress
D.

Watery diarrhea

Correct Answer
D. Watery diarrhea

Explanation
Episodes of celiac crises are precipitated by infections. ingestion of gluten. prolonged fasting. or exposure to anticholinergics. Celiac crisis is typically characterized by severe watery diarrhea.Option A: Irritability. rather than lethargy. is more likely.Option B: Because of the fluid loss associated with the severe watery diarrhea. the child’s weight is more likely to be decreased.Option C: Respiratory distress is unlikely in a routine upper respiratory tract infection.

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