Every pediatric nurse is a mandated reporter, and the exam takes this seriously. These questions cover the injury patterns that raise concern, the mismatch between history and findings that should prompt further assessment, documentation, and exactly what a nurse's reporting obligation is — including what you do not need before reporting.
Question 1
147 of 150. A 6-year-old child with a history of frequent emergency visits sits rigidly on the exam table. The child exhibits a flat affect and remains stoic while the provider sutures a deep facial laceration.
- A) Notify the social worker to evaluate the family dynamic thoroughly.✓
- B) Praise the child for being extremely brave during the procedure.
- C) Administer an additional local anesthetic to ensure complete pain control.
- D) Ask the parent why the child requires frequent emergency visits.
💡 Key Takeaway
A blunted pain response and stoicism in a young child are classic indicators of chronic trauma.
Show rationale
A blunted pain response and rigid posture during a painful procedure are classic signs of chronic trauma or abuse. The nurse should involve social work to evaluate the family for non-accidental trauma. Praising the child (B) reinforces a potentially pathological coping mechanism. Administering more anesthetic (C) misses the behavioral red flag of the stoic demeanor. Asking the parent directly (D) can trigger defensiveness and compromise the child's safety if abuse is occurring.
Question 2
18 of 150. A 15-year-old female is evaluated in the clinic for a minor laceration. The nurse notes newly drawn geometric symbols on her notebooks and a fresh burn mark on her right hand. The patient is evasive when asked about her new older peer group.
- A) Initiate an urgent referral for non-suicidal self-injury therapy.
- B) Assess for gang initiation rituals and related safety risks.✓
- C) Report suspected physical abuse to child protective services immediately.
- D) Provide appropriate wound care and schedule a routine follow-up.
💡 Key Takeaway
Specific symbols combined with localized burns and older peer groups are red flags for gang initiation.
Show rationale
The combination of geometric symbols, which often represent gang insignia, and a burn mark, a common gang initiation or branding method, paired with evasiveness about a new older peer group strongly suggests gang involvement rather than self-injury or abuse. Non-suicidal self-injury typically presents with cutting or scratching on easily hidden areas like the thighs or inner arms, not localized burns paired with specific symbols. While child abuse is always a consideration for unexplained burns, the specific context of drawn insignia and older peers points directly to initiation rituals. Providing only routine wound care ignores the high-risk psychosocial cues and leaves the adolescent in danger.
Question 3
23 of 150. A 12-year-old migrant worker presents with severe pesticide exposure and states his employer holds his passport.
- A) Notify the occupational safety board about the hazardous workplace conditions.
- B) Activate the hospital protocol for suspected pediatric labor human trafficking.✓
- C) Treat the pesticide exposure and discharge the patient back to the employer.
- D) Request a psychiatric evaluation for potential child neglect and physical abuse.
💡 Key Takeaway
Document confiscation combined with hazardous child labor are definitive red flags for pediatric labor trafficking.
Show rationale
This scenario presents clear indicators of pediatric labor trafficking. The combination of hazardous child labor resulting in severe pesticide exposure and the confiscation of identification documents are hallmark signs of exploitation and coercion. Activating the hospital protocol for suspected human trafficking ensures a coordinated, multidisciplinary response involving social work and law enforcement to protect the child. Notifying the occupational safety board addresses the workplace hazard but fails to immediately protect the child from the ongoing trafficking situation. Treating the exposure and discharging the patient back to the employer is incredibly dangerous, as it returns the child directly to the trafficker. Requesting a psychiatric evaluation for neglect misidentifies the core issue; this is a systemic exploitation and trafficking emergency, not a primary psychiatric condition or standard parental neglect, requiring specialized trafficking interventions.
Question 4
49 of 150. A 16-year-old needs a sports physical clearance today, but their parent is working out of state and cannot attend. The parent is available by phone.
- A) Reschedule the physical until the parent returns home.
- B) Obtain verbal telephone consent from the available parent.✓
- C) Allow the adolescent to consent for the physical.
- D) Perform the physical but withhold the clearance form.
💡 Key Takeaway
Telephone consent enables adolescents to receive routine care when working parents cannot be physically present.
Show rationale
Obtaining verbal telephone consent allows the adolescent to receive necessary preventive care while accommodating the parent's occupational travel. Rescheduling (A) creates an unnecessary barrier to the adolescent's participation in extracurricular activities. Minors generally cannot legally consent to a routine sports physical (C), as it does not fall under exceptions like reproductive health or substance abuse treatment. Performing the exam without providing the clearance form (D) defeats the purpose of the visit and frustrates the family.
Question 5
69 of 150. A 9-year-old child has circular purpuric macules on the shoulders. The parent states they used a heated jar to draw out the child's respiratory congestion. Which finding warrants immediate further investigation?
- A) The purpuric macules are perfectly round and symmetrically distributed.
- B) The child reports that the glass jars felt comfortably warm.
- C) The circular lesions are located on the abdomen and genitals.✓
- D) The parent used a small open flame to heat the jars.
💡 Key Takeaway
Cupping marks on atypical, protected areas like the genitals strongly suggest abuse rather than cultural healing.
Show rationale
Traditional cupping is typically performed on the back, shoulders, or chest to treat respiratory ailments. Circular lesions located on the abdomen and genitals are highly irregular for this practice and strongly suggest non-accidental trauma or sexual abuse, warranting immediate investigation. Purpuric macules that are perfectly round and symmetrically distributed are the exact expected findings of a standard cupping treatment. The child reporting that the glass jars felt comfortably warm is consistent with the expected sensory experience of fire cupping and does not raise suspicion. A parent using a small open flame to heat the jars is the standard method for creating the vacuum necessary for traditional fire cupping; while it carries a minor burn risk, it is part of the cultural practice and not inherently indicative of intentional abuse.
Question 6
105 of 150. A 5-year-old non-diabetic child presents with profound, unexplained hypoglycemia requiring continuous dextrose infusions. Laboratory results drawn during a severe hypoglycemic episode reveal elevated serum insulin levels with undetectable C-peptide. The father is the primary caregiver.
- A) Prepare the family for an abdominal MRI to locate an insulinoma.
- B) Assess the father's access to exogenous insulin and notify social work.✓
- C) Consult endocrinology to evaluate for a rare genetic metabolic disorder.
- D) Educate the father on recognizing the early signs of childhood diabetes.
💡 Key Takeaway
High insulin with low C-peptide indicates exogenous insulin administration, requiring immediate safeguarding and investigation.
Show rationale
Endogenous insulin production naturally creates equal amounts of insulin and C-peptide. A lab result showing high insulin but undetectable C-peptide definitively proves the insulin was administered exogenously, pointing directly to medical child abuse. The nurse must assess the caregiver's access to medications and involve social work immediately. Option A is incorrect because an insulinoma would produce high levels of both insulin and C-peptide. Option C delays necessary protective action by pursuing a genetic metabolic disorder when the labs already confirm an exogenous source. Option D is inappropriate because the child does not have diabetes, and educating the suspected perpetrator ignores the immediate safety threat.
Question 7
108 of 150. A 7-year-old child is brought to the clinic for a persistent nocturnal cough. The nurse observes erythematous, symmetric, pine-tree shaped streaks on the child's back. The child denies any pain.
- A) Recognize this as a common dermal response to traditional coining.✓
- B) Report this pattern as highly suspicious for nonaccidental inflicted trauma.
- C) Swab the affected skin areas to evaluate for bacterial cellulitis.
- D) Instruct the parents to apply hydrocortisone cream to the lesions.
💡 Key Takeaway
A symmetric, pine-tree pattern of non-painful ecchymosis on the back is the hallmark presentation of coining.
Show rationale
Coining (Cao Gio) typically produces a pine-tree pattern of symmetric, non-painful ecchymosis along the ribs and spine. This is a common Southeast Asian practice used to treat ailments like a cough or fever by releasing trapped "wind." Recognizing this as a traditional healing practice prevents unnecessary and harmful accusations of abuse. Reporting this pattern as highly suspicious for nonaccidental trauma is incorrect because the symmetry, specific pattern, and lack of pain strongly differentiate it from abuse. Swabbing the affected skin areas for bacterial cellulitis is unnecessary, as the lesions are ecchymotic and mechanical in nature, not infectious. Instructing the parents to apply hydrocortisone cream is inappropriate because the marks are self-limiting bruises, not an inflammatory allergic reaction or dermatitis that would respond to topical steroids.
Question 8
116 of 150. A 2-year-old toddler is brought to the clinic with a minor forehead laceration. When the child cries during the examination, the parent refuses to offer comfort, stating, "He needs to learn to be a man and stop acting like a baby."
- A) Assess the parent-child attachment and document the clinical interaction.✓
- B) Explain the importance of comforting toddlers during medical procedures.
- C) Consult a social worker for immediate emergency foster care placement.
- D) Provide the parent with age-appropriate developmental milestone tracking charts.
💡 Key Takeaway
Withholding comfort from a distressed toddler is a sign of emotional rejection requiring careful assessment.
Show rationale
The parent's refusal to comfort a distressed toddler demonstrates emotional unavailability and rejection, which are risk factors for emotional abuse. The nurse should carefully assess attachment behaviors and objectively document the interaction to build a clinical picture over time or support a future report. Explaining the importance of comfort is a reasonable educational intervention, but it must follow a thorough assessment of the dyad's baseline interaction. Consulting a social worker for immediate emergency placement is an overreaction, as there is no evidence of imminent physical danger or severe neglect warranting removal in this specific moment. Providing developmental milestone charts is a standard anticipatory guidance practice, but it fails to address the immediate concern of parental rejection and lack of nurturing during a stressful event.
Question 9
22 of 150. A 3-year-old presents with a bite mark on the shoulder. The nurse measures an intercanine distance of 2.2 cm on a U-shaped superficial crush wound. The mother suspects the father caused the injury. Which conclusion should the nurse draw?
- A) Document findings as conclusive evidence of adult abuse.
- B) Prepare to administer rabies immune globulin without delay.
- C) Recognize the measurement strongly suggests another child bit.✓
- D) Swab the wound for Pasteurella multocida culture testing.
💡 Key Takeaway
An intercanine distance of less than 2.5 to 3.0 cm typically indicates a bite from a child.
Show rationale
Measuring the intercanine distance helps differentiate between an adult and a child human bite. An intercanine distance of 2.2 cm on a U-shaped superficial crush wound falls well below the typical adult measurement of 3.0 cm or greater, indicating the bite was likely caused by another child. Option C is correct because recognizing this pediatric measurement helps the nurse accurately evaluate the mother's claim about the father. Option A is incorrect because the small distance contradicts adult involvement, making it poor evidence of adult abuse. Option B is incorrect because the U-shaped crush wound indicates a human bite, so rabies prophylaxis is unnecessary. Option D is incorrect because Pasteurella multocida is associated with animal bites, not human injuries.
Question 10
40 of 150. A 16-year-old completes the PHQ-9A and endorses active suicidal ideation with a plan. The adolescent begs the nurse not to tell their parents about these thoughts. How should the nurse respond?
- A) Promise strict confidentiality to maintain the therapeutic relationship.
- B) Contact child protective services to report potential abuse.
- C) Explain that safety concerns require informing the parents.✓
- D) Discharge home with a twenty-four-hour crisis hotline number.
💡 Key Takeaway
Patient safety always supersedes confidentiality when an adolescent expresses active suicidal ideation or intent.
Show rationale
When an adolescent poses an imminent risk to themselves, safety supersedes confidentiality. The nurse must clearly explain that parents must be informed to ensure a safe environment. Promising strict confidentiality is dangerous and violates ethical safety standards. Contacting child protective services is inappropriate unless there is specific evidence of abuse causing the ideation. Discharging the patient home with just a hotline number constitutes patient abandonment during a psychiatric emergency.
