AACN CCRN (Pediatric) Exam Questions

Correct answer: Generalized tonic-clonic seizure (GTC)

The most common type of seizure requiring ICU admission is GTC status epilepticus (formerly known as grand mal seizure). Status epilepticus is defined as a prolonged seizure or multiple consecutive seizures without regaining consciousness. 

Focal seizures start in one part of the brain and may stay local or spread to other areas in the brain. Absence and myoclonic tonic seizures are other types of generalized seizures, originating in the cortical or subcortical areas of the brain and spreading bilaterally. 

Correct answer: 15 minutes 

The nurse should stay with the patient for the first 15 minutes of the blood infusion to monitor for signs and symptoms of a transfusion reaction. This allows for the nurse to detect a reaction and intervene swiftly. 

The first 15 minutes are the most critical and the most likely time a transfusion will occur. During a transfusion, vital signs are monitored every 30 minutes to 1 hour according to hospital policy. 

Correct answer: Serum glucose of 110 mg/dL

Septic shock is caused by infectious organisms or their endotoxins stimulating the immune system and triggering activation of inflammatory mediators within the body. Patients may be hyperthermic or hypothermic and often have elevated WBC counts (or decreased WBC counts with a left shift in the differential), metabolic acidosis, and elevated lactate levels. 

If treatment is working, the body's organs and tissues are receiving adequate perfusion, and the patient will show improvements clinically. Normal serum glucose levels in adolescent patients are between 70 mg/dL and 120 mg/dL. A serum glucose level of 110 mg/dL is within normal limits and indicates improvement.

MAP should be at least 65-70 mmHg, urinary output should be at least 30 mL/hr, and serum lactate levels should be below 2 mmol/L. 

Correct answer: Asthma 

Asthma prevalence, morbidity, and mortality are increasing in the United States. These increases may result from worsening air pollution, poor access to medical care, and underdiagnosis or undertreatment. 

Asthma is the most common chronic disease of childhood, the primary cause of school absences, and the third leading cause of hospitalizations in children younger than the age of 15 years. 

Correct answer: Prostaglandins (PGE1)

HLHS is the most common congenital heart defect involving single-ventricle physiology. It is characterized by various levels of underdevelopment of left heart structures. A PDA and ASD (atrial septal defect) are obligatory for survival. 

With HLHS, systemic venous blood returns normally to the right atrium (RA) and flows normally from the right side of the heart. Pulmonary venous blood flows across the ASD to the RA because it cannot exit the left side of the heart if mitral atresia is present. Mixing of pulmonary and systemic blood desaturates the blood. Blood shunts from right to left across the PDA to supply systemic blood flow distally and flows proximally to feed the coronary arteries.

Because of this pathology, ductal patency must be maintained with prostaglandin therapy until staged surgical reconstruction can be done. 

Indomethacin promotes PDA closure. Milrinone and NO are pulmonary vasodilators and do not affect PDA. 

Correct answer: Diastolic left HF 

Diastolic left HF (left ventricular diastolic dysfunction) results from the inability of the left ventricle during diastole to fill with blood adequately. This is due to ventricular restriction or noncompliance (too stiff), resulting in decreased CO to the systemic circulation and symptoms of CHF; blood backs into the lungs, causing the patient to experience shortness of breath. 

Diastolic right HF (right ventricular diastolic dysfunction) is due to the inadequate filling of the right heart during diastole due to ventricular restriction or noncompliance, resulting in decreased CO to the pulmonary circulation and decreased return to the left atrium, compromising left-sided CO. 

Systolic right HF (right ventricular systolic dysfunction) is the inability of the right heart to provide adequate pulmonary blood flow. This leads to increased right heart preload and systemic venous congestion. 

Systolic left HF (left ventricular systolic dysfunction) is the inability of the left heart to provide adequate systemic blood flow and oxygen delivery, resulting in increased left heart preload and/or afterload. This leads to pulmonary congestion and low CO. 

Correct answer: Hemoglobin level of 12 g/dL

Hemoglobin levels are utilized to evaluate the effectiveness of a blood transfusion. Normal hemoglobin levels for a 10-year-old female are between 11 and 14.5 g/dL. Thus, a hemoglobin level of 12 g/dL indicates the transfusion was successful in this patient. 

Correct answer: Use short and simple sentences, limiting descriptions to concrete explanations

A child aged 3-5 is considered to be a preschooler. The nurse should recognize the developmental stages of this age group and explain in simple terms what a chest tube is, using limited descriptions and concrete explanations. The nurse may allow the child to inspect and touch the equipment as indicated and include the child frequently, making the experience as friendly and nonthreatening as possible. The nurse should avoid using words like, "cut," "take," "broken," or "put you to sleep." 

The other options are indicated for older children. While it is acceptable to explain the procedure to the parents as well, they should not be primarily responsible for explaining the procedure to the child. 

Correct answer: Partial-thickness burns greater than 9% total body surface area (TBSA)

The American Burn Association (ABA) has established a set of criteria for referring patients to a burn-specific critical care environment, to receive specialized care for certain types of burn injuries. Any child who suffered partial-thickness (second-degree) burns over greater than 10% of their total body surface should be referred to a burn center. 

Additional criteria include burns that involve the face, hands, feet, genitalia, perineum, or major joints; third-degree (full-thickness) burns in any age group; electrical burns; chemical burns; inhalation injury; burns on patients with preexisting medical conditions that could complicate management; any patient with burns and concomitant trauma in which the burn poses the greatest risk of morbidity and mortality; and burn injury in patients requiring specialized social, emotional, or rehabilitative intervention. 

Correct answer: 12 to 24 hours after birth 

The ductus arteriosus is a structure that should be present in utero, as it permits blood flow to be diverted away from the high-resistance pulmonary circulation to the descending aorta and the low-resistance placental circulation. Patent ductus arteriosus (PDA) occurs when the vessel that normally connects the aorta and pulmonary artery in utero has failed to close at birth, which leads to a left-to-right shunting of blood. Blood flow to the lungs will be increased as a result of this abnormal shunting, which can cause pulmonary hypertension and eventually lead to left-sided heart failure (particularly if the PDA is large). 

Closure normally occurs 12-24 hours after birth, which is initiated by a rise in the perivascular PO₂ and a decrease in endogenous prostaglandin (producing functional closure). 

Anatomic closure occurs between 2 and 3 weeks and is produced by fibrosis of the ductal tissue with permanent sealing of the lumen to produce the ligamentum arteriosum. Following anatomic closure, the ductus cannot be reopened. 

Correct answer: Denial

Feelings of shock, disbelief, and rejection of tragic news are generally immediate responses to grief. This immediate denial of the situation protects the individual from the shocking reality of loss by postponing the full effect of reality until their psyche can handle it. During this initial stage of grief, people experience overwhelming feelings of being stunned and surprised, often manifesting as emotional numbness, flat affect, or immobility. 

Anger follows denial or emotional numbness, then comes bargaining, followed by depression and withdrawal. Acceptance is the resolution stage of the grief process, which is characterized by emotional detachment of life's meaning from the lost relationship and reestablishing independent meaning.

Correct answer: Increased contractility and reduced preload 

Myocardial dysfunction causes inadequate perfusion and leads to cardiogenic shock. Common causes include congenital heart disease (CHD), myocarditis, cardiomyopathy, sepsis, arrhythmias, drug toxicities, and damage to the heart. Cardiogenic shock is characterized by extreme tachycardia, high systemic vascular resistance (SVR), and decreased cardiac output (CO). Other symptoms besides tachycardia are increased work of breathing leading to respiratory distress, hepatomegaly, jugular vein distention (JVD), low BP with narrow pulse pressure, weak or absent peripheral pulses, delayed capillary refill with cool extremities, diaphoresis, and decreased level of consciousness (LOC). 

Goals include improving oxygenation and blood flow (increasing CO) through the reduction of metabolic demand and afterload, optimization of preload, increased myocardial relaxation, and respiratory support. Preload is decreased with the use of diuretics. Inotropic agents are used to increase contractility. After the patient has been stabilized, vasodilating agents may be used to further reduce both preload and afterload. 

Correct answer: Autoimmune hemolytic anemia (AIHA) 

The Coombs test, or DAT, is used to detect antibodies that act against the surface of the patient's RBCs, indicating a condition known as AIHA. In this condition, the RBCs are prematurely destroyed, so the body's RBC store is constantly being depleted, resulting in anemia. Clumping of RBCs occurs if the RBCs are coated with antibodies or complement. The greater the number of antibodies against the RBCs is, the more clumping will occur. Any clumping is read as a positive result using a scale of 1 to 4+. Coombs test differentiates types of hemolytic anemia and detects immune antibodies. 

Indirect Coombs testing is a type of antibody screening that detects specific serum antibodies (IgG) to RBC antigens that are in the serum but not attached to the RBCs. It is used to detect IgG-positive antibodies in maternal blood and newborns and is performed before RBC transfusions to detect incompatibilities other than major ABO groups. 

Erythrocyte sedimentation rate (ESR) is a nonspecific indicator of an acute inflammatory response and is often used in conjunction with other laboratory values to assess inflammation.

Histocompatibility testing identifies HLA antigens.

Correct answer: Narrow pulse pressure 

Cardiac tamponade can occur from a contusion or from penetrating trauma, resulting in blood or fluid accumulation in the pericardial sac. This accumulation of fluid around the heart impairs ventricular filling, reduces cardiac output (CO), and causes hypotension (not hypertension) due to decreased preload. A narrow pulse pressure is the result of increased diastolic pressure to compensate for the low CO, as the external pressure on the heart inhibits the ventricles from relaxing. 

CVP is elevated in cardiac tamponade, not decreased. Tachycardia is present, not bradycardia. 

Correct answer: Type II

Salter-Harris fractures are usually caused by traumatic injuries and involve injury to the growth plate (physeal fracture). Wrist and hand injuries usually are "Salter" type fractures involving the physis. "SALTER" is a mnemonic, referring to the fracture line and its relationship to the growth plate.

• S (type I fracture): Straight across; disrupt the physis 
• A (type II fracture): Above the growth plate; involves a break from the growth plate up into the metaphysis (at an angle), with the periosteum usually remaining intact; this is the most common pediatric physeal fracture, occurring frequently in children over 10 years of age
• L (type III fracture): Lower or beLow: intra-articular fractures through the epiphysis that extend across the physis
• T (type IV fracture): Two or Through; cross the epiphysis, physis, and metaphysis
• ER: (type V fracture): ERasure of growth plate or CRush; compression injuries to the physis

Correct answer: Tricuspid atresia 

TGA is a congenital heart defect in which the pulmonary artery and aorta are switched positions: the left ventricle gives rise to the pulmonary artery, and the right ventricle gives rise to the aorta, resulting in parallel circulations. "Simple" TGA is associated with ASD, VSD, and PDA 80% of the time. 

Systemic venous blood enters the right side of the heart normally but exits through the aorta, sending deoxygenated blood back to the body instead of the lungs. Pulmonary venous blood enters the left side of the heart normally but exits through the pulmonary artery, sending oxygenated blood to the lungs instead of the body. 

TGA is not commonly associated with tricuspid atresia. 

Correct answer: Type O

For blood transfusions, the donor's blood and the recipient's blood must be tested for compatibility. If the blood is not compatible, a life-threatening transfusion reaction can occur. 

However, the universal red blood cell donor is type O negative; O-negative unmatched blood may be given to patients with an urgent, life-threatening need for a blood transfusion. Type AB positive is known as the universal recipient.  All other blood types must be tested for compatibility before administering. 

Correct answer: Sepsis 

A perforated appendix is a common cause of peritonitis (inflammation of the serous membrane lining the abdominal cavity and covering the viscera), as the inflammatory response causes exudation of fluid from the appendix into the peritoneal cavity. Sepsis is the most serious complication and a major cause of death from peritonitis. 

Other complications include hypovolemia, abscess formation, and shock (resulting from hypovolemia or septicemia). 

Correct answer: Computerized tomography (CT) scan 

A CT scan remains the gold standard for the acute evaluation and diagnosis of TBI. It uses a series of x-rays to create detailed images of internal areas of the skull, showing internal swelling, bleeding in the brain, and any skull fracture(s) present. A CT scan is the first test used after a TBI. 

The other neuroimaging scans and tests aid in determining the extent of TBI, help with surgical planning and specific interventions, and are critical in long-term therapy after the initial injury (identifying sequelae, determining prognosis, and rehabilitation guidance). 

Correct answer: Types 2 and 3 

Open fractures are divided into three types:

• Type I: Clean puncture with minimal soft-tissue involvement; treat with casting with a window cut to allow for healing visualization and dressing changes
• Type II: Involve >1 cm laceration with slight or moderate crushing and no extensive soft-tissue damage
• Type III: Extensive damage to soft tissues, muscle, skin, and neurovascular structures; contamination is present; treatment with wound irrigation and IV antibiotics is necessary; debridement every 24 to 48 hours until the wound is clean

Type II and III injuries may be treated with external fixation.