ENPC 4th Edition Practice Test.pdf file:///C:/Users/HP/Desktop/New%20folder%20(3)/ENPC%204th%20
ENPC 4th Edition Practice Test Questions &
Answers with Rationale
1. 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 haveit
covered. What is the developmental reason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their in-
sides 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 ifleft
uncovered.
D.) Preschoolers are concerned with body image and don't want to appear
different than peers
Answer A.) Preschoolers are magical thinkers and imagine bandageskeep their insides
from coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty distin-
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guishing 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. 2. 7-month-old presents to the emergency department with a complaint of
fever. Assessment reveals a patent airway and slight cyanosis around his lipsand
nail beds. He is alert and interactive. His vital signs are 38.5 C (101.3F), HR134,
RR 32, BP 78/54 mm Hg, and Spo2 84%.The nurse notes a healed surgicalscar 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
Answer 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 likelyfrom
a congenital heart defect repair. The mother's chief complaint is the fever, notthe color,
pulse oximetry, or the respiratory distress. This may be because these aspects of his
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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 fromthe caregiver before
any intervention.
3. 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 performsan
across-the-room assessment. He is staring at the wall. He has no increasedwork
of breathing, and his color is pink. Using the pediatric assessment triangle
(PAT), what classification will the nurse assign?
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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, butit
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 componentsof
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