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The nurse is completing the admission assessment
of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding
is evidence that the child is experiencing increased
intracranial pressure (ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging
fontanels
D. Blood pressure fluctuations and syncope
2. A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum
amylase. Which additional information is the client
most likely to report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly.
3. A child newly diagnosed with sickle cell anemia (SCA)
is being discharged from the hospital.Which information is most important for the nurse to provide the
parents prior to discharge?
A. Instructions about how much fluid the child should
drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief
measures
D. Referral for social services for the child and family
4. To auscultate for a carotid bruit, the nurse places the
stethoscope at what location. (Select the location on
the image with a red dot).
B. Sluggish and
unequal pupillary
responses
A. Abdominal pain
decreases when
lying supine
A. Instructions
about how much
fluid the child
should drink daily
I placed the red
dot on the base
of the neck on the
right side
5. After receiving report on an inpatient acute care unit, D. The client with
which client should the nurse assess first? a bowel obstruc-
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