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-