AACN CCRN (Pediatric) Exam Questions

Correct answer: Cheyne-Stokes respirations

Cushing's triad includes three primary signs that often indicate an increase in intracranial pressure (ICP). These signs are: 

• increased systolic blood pressure (widening pulse pressure)
• decreased pulse (bradycardia)
• irregular respirations

Cheyne-Stokes respirations are characterized by a shallow breathing pattern, building to deep and then back to shallow respirations; they are a common indicator of an increased ICP. 

When a pediatric patient presents with vital signs that are seemingly the opposite of those of shock (e.g., decreased blood pressure, increased pulse, and increased respirations), they are most likely experiencing an increase in ICP. 

Correct answer: Exudate on tonsils 

Acute epiglottitis is a severe, life-threatening condition requiring immediate medical attention. It primarily affects children ages 2 to 5 years but can occur from infancy to adulthood; it is characterized by a rapidly progressing bacterial infection of the epiglottis and surrounding area. The patient's history usually reveals an acute onset of symptoms, including a high fever, a sore throat and difficulty swallowing, dyspnea, and rapidly progressing respiratory obstruction from swelling tissue. The obstruction is supraglottic as opposed to subglottic (as seen in laryngitis). Stridor is a late finding and suggests near-complete airway obstruction. 

Exudate on tonsils is not a clinical finding associated with epiglottitis. 

Correct answer: Pathologic jaundice appears within the first 24 hours after birth 

Pathologic jaundice appears within the first 24 hours after birth for a normal full-term newborn. The clinical course of nonpathologic (or physiologic) jaundice is characterized by a progressive increase in transcutaneous serum bilirubin (TSB) concentration up to a mean peak of 5 to 7 mg/dL between 3 and 4 days after birth. Levels usually normalize by 2 weeks of age; no hepatosplenomegaly is present in physiologic jaundice. 

Physiologic jaundice is transient hyperbilirubinemia that is frequently observed in otherwise completely healthy newborns. It often begins in the head/face and progresses down the body. 

Jaundice within the first 24 hours after birth is pathologic. The risk of pathologic jaundice increases with decreasing gestational age, in infants born before 38 weeks of gestation who are receiving human milk, and in ill neonates. 

Correct answer: Abdominal ultrasound 

An abdominal ultrasound is recommended as initial imaging for a case of acute pancreatitis, as it can confirm the diagnosis and assist with identifying contributing abnormalities.

An abdominal CT scan is the second most common imaging method, as it can diagnose and identify etiologies and visualize masses, necrosis, and hemorrhage. The use of MRCP is controversial for an initial episode of acute pancreatitis; it can detect intrahepatic and pancreatic duct abnormalities. EGD is not indicated for the diagnosis of acute pancreatitis. 

Correct answer: Compensated respiratory acidosis 

This patient's pH is below the normal range of 7.35-7.45, indicating acidosis. The PaCO₂ is elevated at 51 mm Hg (normal range is 35-45 mm Hg), indicating respiratory acidosis. The HCO₃ is also elevated, indicating metabolic alkalosis. However, the value that is consistent with the pH (acidotic) is PaCO₂ (acidotic), signifying a primary respiratory acidosis. The acid-base component that is inconsistent with the pH is HCO₃ (as it is elevated), indicating metabolic alkalosis, so compensation signifies a non-acute primary disorder. The compensation is evidenced by the metabolic system acting to correct the primary acidosis (marked by an elevation of HCO₃). 

Lastly, PaO₂ is decreased (normal values 80-100 mm Hg), indicating an abnormality with oxygenation. However, a thorough history and physical exam will help assess the severity and urgency of indicated interventions, if any.

Correct answer: Syndrome of inappropriate antidiuretic hormone (SIADH) 

SIADH is seen often in pediatric critical care and is the result of excess ADH; it occurs when ADH release is not able to be suppressed, leading to hyponatremia (serum sodium levels below 135 mEq/L) and impaired water secretion. 

T1DM does not cause hyponatremia. Hypernatremia (serum sodium levels greater than 145 mEq/L) is associated with severe dehydration and DI. 

Correct answer: Pancreatic enzymes must be given every time the child eats 

Cystic fibrosis (CF) is an autosomal recessive disorder in which a mutation of the CFTR gene causes defective epithelial ion transport, leading to dehydrated, viscous secretions. These abnormal secretions cause "mucus plugs" that obstruct tubular structures in the upper and lower airways, vas deferens, gut, liver, and pancreas. When mucus clogs the patient's pancreas, pancreatic enzymes are unable to be released into the small intestines to break down and digest food. Thus, pancreatic enzymes must be given to the child every time the child eats to ensure proper digestion. 

The other choices are not indicated in the case of CF. 

Correct answer: 400 to 800 mcg 

The major environmental factor linked to NTDs is the dietary level of folic acid. Folic acid supplementation before and during pregnancy (particularly through the first trimester) has been cited as substantially lowering the incidence of these NTDs. The AAP recommends daily administration of 400 to 800 mcg of folic acid daily to all childbearing-age females to prevent NTDs. 

Correct answer: A generalized seizure 

Generalized seizures (convulsive or nonconvulsive) originate in the cortical or subcortical areas in the brain and quickly spread bilaterally, affecting both sides of the brain. Generalized seizures include: 

• absence seizures
• myoclonic seizures
• clonic seizures
• tonic seizures
• atonic seizures

Focal seizures start in one part of the brain and either stay local or can spread to other areas of the brain. Status epilepticus is defined as a prolonged seizure (usually 30 minutes or longer) or multiple consecutive seizures without regaining consciousness. A febrile seizure occurs in the setting of a fever. 

Correct answer: Retinal hemorrhage(s) 

The most well-known form of child abuse is shaken baby syndrome, which occurs in children younger than 2 years. Violent shaking leads to the formation of a subdural hematoma, metaphyseal chip fractures, and retinal hemorrhages. Any of the following fractures could be present: an avulsion fracture of the spinous process, fracture of the pars or pedicle, or compression of multiple vertebral bodies from severe shaking or battering (usually in the cervical spine area). The child often presents for seizure activity in cardiac arrest or with a history of a seizure.

The definitive finding in shaken baby syndrome is the presence of retinal hemorrhages. Careful ocular examinations are vital for any young child who presents with a vague history, who has seizures, or who is/has suffered cardiac arrest. A child with retinal hemorrhages often ends up with permanent vision damage, as the retina cannot regenerate.  

Correct answer: Cardiac catheterization 

The initial evaluation for PH consists of ECG and echocardiogram; BNP level (inversely proportional to prognosis in PH), and chest x-ray. 

Cardiac catheterization confirms the diagnosis (after the initial workup has been completed) and assesses the severity of the disease. Cardiac catheterization is also helpful to assess the response to pulmonary vasodilators before starting therapy, evaluate the response to or the need for changes in therapy, exclude other potentially treatable diagnoses, and assist in the determination of suitability for heart or heart-lung transplantation. 

Correct answer: Bronchopulmonary dysplasia (BPD)

BPD, also known as chronic lung disease of prematurity, is the lung's response to acute injury at critical periods of lung growth that is multifactorial and not completely understood. Risk factors for BPD include prematurity, mechanical lung overdistention or volutrauma, oxygen toxicity, infections, pulmonary vascular damage and edema, and deficiency or dysfunction of lung surfactant. 

Chronic hypoxemia in BPD is the result of a multitude of factors, including increased bronchial smooth muscle, bronchial mucosa hyperplasia, loss of cilia, and inflammatory infiltrates. All these factors lead to a reactive airway with diminished capacity. 

Correct answer: Secure the drain by curling excess tubing and taping it firmly to the abdomen 

Surgical drains, such as the Jackson-Pratt drain, may be placed in or near surgical wounds to prevent fluid buildup and must be maintained properly until the fluid amounts from the wound begin to lessen. The Jackson-Pratt drain is active, meaning the chamber expands and creates suction to remove fluid from the wound. In order for the drain to function, the suction bulb must be depressed and emptied at scheduled intervals or when full in order for suction to be maintained. The drain should be frequently checked for patency, and intake and output should be documented every 4 hours or more (if full). Bright red bloody drainage may indicate surgical bleeding and should be closely monitored. 

The drain should be secured to prevent inadvertent dislodgement but should not be curled or folded because this could prevent the flow of drainage. 

Correct answer: Chemical 

Burns can be classified into four main categories: thermal, electrical, chemical, and radiation. Thermal burns can be further divided into subtypes of scald, flame, contact, and hypothermic. 

The most important first-aid treatment for burn injury victims is minimizing the burn wound depth and extent by eliminating the source of the injury and stopping the burning process. The burn(s) should next be covered with clean, dry linen, and body heat should be conserved at all costs (particularly for infants and young children). The nurse should follow the "ABCDE" primary assessment methodology, beginning with airway and breathing and followed by circulation, disability, and finally, exposing/examining the wound. 

Wound care is not an essential component of initial emergency care, except in chemical burns. Chemical burns occur when the skin is directly exposed to causative chemicals, such as acids, alkalis, or organic compounds. In these cases, the chemical agent must be immediately removed from the wound, either in the field or at the primary hospital. 

Generally, a patient who sustains a chemical burn will be transferred to a burn center for more extensive wound care (manual debridement and/or topical antimicrobial administration).  

Correct answer: Hemolytic anemia and abnormal peripheral blood smear 

Diagnostic findings for a sickle cell patient include a peripheral blood smear with sickled erythrocytes. Hemoglobin electrophoresis indicates the precise type of hemoglobinopathy as it differentiates between types of hemoglobin and reports the percentage of blood composition of each. A complete blood count (CBC) reflects hemolytic anemia with reduced hemoglobin, hematocrit, and RBC count because the spleen has destroyed the sickled cells. Platelets and reticulocyte count may be elevated as a compensatory response to anemia.

Bilirubin may be elevated because of hemolysis of the sickled cells. Leukocytosis and positive blood cultures are not likely unless an infection is present. Liver enzymes are not elevated. 

Correct answer: Rhythm originating in the SA node 

Sinus tachycardia is recognized on ECG with a normal upright P wave (not inverted) preceding every QRS complex (P:QRS ratio of 1:1). The PR interval and QRS configuration are normal (there is no prolonged pause), the rhythm is regular, the heart rate is increased (can be as high as 250 bpm, overlapping with rates of supraventricular tachycardia [SVT] in neonates), and the pacemaker is coming from the SA node and not elsewhere in the atria.

Sinus tachycardia is almost always the result of an underlying condition and is rarely a primary cardiac arrhythmia. Most commonly, treating the underlying cause will resolve this condition. The heart rate is increased but regular in sinus tachycardia. If there is an inverted P wave noted on ECG, this generally indicates an ectopic atrial rhythm not originating in the SA node (non-sinus origin of the P waves). 

Correct answer: Holter monitoring 

Heart failure (HF) is a condition in which the heart is unable to provide adequate cardiac output (CO) or regional blood flow to meet the circulatory and metabolic requirements of the body. A history and a physical examination are often performed first, providing lots of clues to both the etiology and severity (presenting signs and symptoms) of HF. Diagnostic tests include chest x-ray, ECG and echocardiogram, PA catheter placement and/or cardiac catheterization, SVO₂ measurements, laboratory studies including BNP levels, and cardiac MRI. 

Holter monitoring provides a 24-hour record of ECG activity (heart rate and rhythm). It is used to document arrhythmias and/or conduction disorders at rest and under stress, as well as the frequency of their occurrence. It does not aid in the diagnosis of HF. 

Correct answer: A decreased serum osmolality 

SIADH is a common disorder in pediatric critical care and is characterized by excess ADH (i.e., the release of ADH is not able to be suppressed), resulting in hyponatremia and impaired water excretion. When the body senses a rising osmolality, ADH is released to cause water retention or volume expansion. In this syndrome, excess ADH acts on the renal collecting ducts to become more permeable to water, causing dilutional hyponatremia (decreased serum sodium) and a hypoosmolar state (serum osmolality will be decreased). 

In addition to hyponatremia and hypoosmolality, a relative increase in the concentration of urine occurs with high specific gravity and increased urine osmolality (above 100 mOsmol/kg) because of ADH's effect on the renal tubules, resulting in increased water reabsorption by the kidney. 

Correct answer: The bleeding has extended into the ventricular system of the brain

IVH is a major complication of prematurity and the incidence increases with decreasing gestational age and birth weight. A classification system has been put into place to determine the severity and grading of IVH based on the presence and amount of blood in the germinal matrix and lateral ventricles of the brain. 

• Grade 1: germinal matrix hemorrhage only (mild bleed)
• Grade 2: IVH without ventricular dilation (bleed extending into the ventricular system of the brain)
• Grade 3: IVH with ventricular dilation 
• Grade 4: intraventricular and parenchyma hemorrhage 

Correct answer: Coarctation of the aorta 

Aortic coarctation is the congenital narrowing of the aorta, the main blood vessel that carries blood from the heart to the rest of the body. This deformity results in an increased blood pressure proximally and a decreased pressure distally. Coarctation occurs in about 8%-10% of cases of congenital heart disease and is more common in boys. It is frequently associated with PDA, VSD, aortic stenosis, aortic insufficiency, bicuspid aortic valve, mitral and tricuspid valve anomalies, and DiGeorge syndrome. 

Examination of the infant reveals a heaving precordium, equally diminished pulses if the ducts are still open, and a nonspecific systolic murmur at the LSB. In a child, however, there is a blood pressure differential between the upper and lower extremities, systemic hypertension, and a short systolic ejection murmur at the LSB. 

TOF is an obstructive heart defect with signs and symptoms that include irritability, cyanosis, loss of consciousness, seizures, and possible cardiac arrest. A VSD may lead to heart failure due to increased energy requirements, prompting fatigue and pulmonary hypertension (caused by increased blood flow to the lungs). Tricuspid atresia occurs when the tricuspid valve fails to form, resulting in increased pulmonary blood flow with clinical manifestations of congestive heart failure and fluid overload. Survival is contingent upon the placement of an obligatory right-to-left atrial shunt.