N396 Exam 2 Mock NCLEX-Style Exam

A nurse is assessing an infant with increased intracranial pressure (ICP). Which finding is the most concerning?

• High-pitched cry

• Flat fontanelle

• Soft stool

• Normal temperature

A 6-year-old child is admitted with a tonic-clonic seizure. What is the nurse's priority action during the seizure?

• Place a tongue blade in the mouth

• Restrain the child to prevent injury

• Turn the child to a side-lying position

• Offer oxygen via nasal cannula

A child is diagnosed with hydrocephalus. Which finding indicates a need for immediate intervention?

• Prominent forehead

• Vomiting upon waking

• Head circumference unchanged for 2 days

• Soft fontanelle

The nurse is caring for a child post-op from VP shunt placement. Which intervention has highest priority in the first 24 hours?

• Encourage ambulation

• Keep child flat

• Elevate HOB 45 degrees

• Restrict fluid intake

Tags

NGSS.HS-LS1-3

Which finding would be most indicative of Cushing's triad in a child with suspected ICP?

• Hypotension, tachycardia, normal respirations

• Hypertension, bradycardia, irregular respirations

• Tachycardia, hypotension, fast respirations

• Decreased LOC, high fever, hypoventilation

Which of the following is characteristic of an absence seizure?

• Sudden stiffening of limbs

• Loss of awareness and lip smacking

• Jerky movements of arms and legs

• Muscle flaccidity followed by convulsions

The nurse is preparing to administer baclofen to a child with cerebral palsy. What is the intended effect of this medication?

• Reduce salivation

• Control seizures

• Increase muscle tone

• Decrease muscle spasms

A child with meningitis has a positive Brudzinski sign. What does the nurse expect?

• Resistance to leg extension

• Pain when the neck is flexed

• Leg flexion when the neck is flexed

• Vomiting when upright

Which is a priority nursing action for a child in status epilepticus?

• Administer oral glucose

• Apply restraints

• Call rapid response

• Start oral anticonvulsants

Which finding is most consistent with moderate dehydration in a toddler?

• Bounding pulses

• Capillary refill <2 seconds

• Sunken fontanelle and dry mucous membranes

• Polyuria

Tags

NGSS.HS-LS1-3