128

129

OVERVIEW ON IMCI COUGH OR DIFFICULTY OF BREATHING DIARRHEA

FEVER EAR PROBLEM MALNUTRITION AND ANEMIA

130
OVERVIEW ON IMCI
1. The primary objective of Integrated Management of Childhood Illness (IMCI) is
a. Reduce morbidity and mortality among children
b. Identify the disease and classify treatment
c. Health promotion through health teaching and counseling
d. To target 90-100% of children fully immunized
2. All of the following principles are correct about Integrated Management of Childhood Illness
(IMCI), except:
a. The IMCI guidelines address most, but not all, of the major reasons a sick child is brought to a
clinic
b. The guidelines under IMCI do not describe the management of trauma or other acute
emergencies due to accidents or injuries.
c. All sick children must be routinely assessed for major symptoms
d. A combination of individual signs leads to a childs diagnosis
3. The six management process of Integrated Management of Childhood Illness (IMCI) in order
are:
a. Classify the illness, Assess the child, identify treatment, give follow up care ,counsel the
mother
b. Assess the child, classify the illness, identify treatment, counsel the mother, give follow up
care
c. Assess the child, identify treatment, classify the illness, give follow up care, counsel the
mother
d. Assess the child, identify treatment, classify the illness, counsel the mother, give follow up
care
4. According to the Integrated Management of Childhood Illness (IMCI) chart, a sick child is under
the age group of
a. Birth to 5 years old
b. 2 months to 2 years old
c. 2 months to 5 years old
d. 1 week to 2 months
5. In Integrated Management of Childhood Illness (IMCI), color-coded triage system is used to:
a. Identify the appropriate treatment
b. Prioritize care
c. Classify patient
d. All the options
6. A mother brings the child to the clinic. The nurse determines if this is an initial visit or followup visit. If it is an initial visit, what will the nurse use:
a. Give follow up care
b. Assess and treat the child
c. Assess and classify the child
d. Assess and give health teachings
7. A sick child in the pink classification is described as a child
a. who is severely dehydrated according to plan C and referral is no longer necessary

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b. with any danger sign is referred to the hospital after giving the first dose of appropriate
antibiotics
c. with any danger signs needs urgent attention
d. All of the above
8. For children with pink classification, the nurse should:
a. Give essential treatment before sending to hospital
b. Give Vitamin A and complete the first dose vaccine
c. Develop an integrated plan and give the first dose of medication in the center
d. Counsel the mother and remind the parent when to return
9. The following assessments are to be done by the nurse before checking the general danger
signs, except:
a. Ask the mother what is/are the problems of the child
b. Determine if it is an initial or follow up visit
c. Assess if the child has cough or difficulty of breathing
d. Determine the age of the child
10. Among the following severe conditions in the pink box, which does not always require urgent
referral to a hospital?
a. Severe febrile disease
b. Severe pneumonia
c. Severe dehydration
d. Mastoiditis
11. In a sick child, age 3, the following are in the yellow classification, except
a. Pneumonia
b. Some dehydration
c. Mastoiditis
d. Malaria
12. In assessing the patients condition using the Integrated Management of Childhood Illness
approach strategy, the first thing that a nurse should do is to:
a. Check for the four main symptoms
b. Check for the general danger sign
c. Ask what is the childs problem
d. Check the patients level of consciousness
13. If a child is 2 months to 5 years, which of the following steps is not appropriate in checking
for general danger signs?
a. Ask if the child is feeding well
b. Ask if the child has fever
c. Ask if the child has convulsions
d. Look and see if the child is abnormally sleepy or difficult to awaken
IMCI SYMPTOM: COUGH OR DIFFICULTY OF BREATHING
14. A mother brought her daughter, 4 years old, to the RHU because of cough and colds.
Following the IMCI assessment guide, which of the following is a danger sign that indicates the
need for urgent referral to a hospital?
a. Signs of severe dehydration

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b. Cough for more than 30 days
c. Inability to drink
d. High grade fever
15. Which of the following is the most important responsibility of a nurse in prevention of
unnecessary deaths from pneumonia and other severe disease?
a. Weighing the sick child
b. Provision of careful assessment
c. Giving antibiotics
d. Taking the temperature of the sick child
16. Which of the following findings indicate fast breathing?
a. Respiratory rate of 60 or more breaths for a 6 weeks old infant
b. Respiratory rate of 50 or more breaths for a 2 weeks old infant
c. Respiratory rate of 50 or more breaths for a 15 months old child
d. Respiratory rate of 40 or more breaths for a 2 months old child
17. A 4-month old infant was brought to the health center because of cough. Her respiratory rate
is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment,
her breathing is considered:
a. Normal
b. Slow
c. Fast
d. Insignificant
18. Assessment for cough or DOB includes these except:
a. Look for chest indrawing
b. Assess for the presence of blood in the sputum
c. Ask for duration of cough
d. Listen for stridor or wheezes
19. A nurse suspects chronic cough if the duration is more than:
a. 6 months
b. 30 days
c. 4 weeks
d. 2 weeks
20. Which of the following signs will indicate that a young child is suffering from severe
pneumonia?
a. Wheezing
b. Chest indrawing
c. Dyspnea
d. Fast breathing
21. Using IMCI guidelines, you classify a child as having severe pneumonia. What is the best
management for the child?
a. Instruct the mother to increase fluid intake
b. Instruct the mother to continue breast feeding.
c. Refer him urgently to the hospital
d. Prescribe an antibiotic

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22. After 3 days, the nurse notes that the child for follow-up care has chest indrawing and stridor.
Her mother returned him to the health center immediately. The nurse should:
a. Advice mother to observe the child and continue giving the antibiotics
b. Observe the child in the health center
c. Change the medicine to the second line antibiotics
d. Give first dose of antibiotics and refer urgently
23. The nurse should consider the following in assessing the child for chest in-drawing EXCEPT:
a. The lower chest goes in when the child breathes in
b. Chest in-drawing should be present at all time
c. The lower chest wall does not go in when the child breathes in
d. The child should be calm
24. A 3-year-old boy is brought by his mother with complaint of rapid breathing. The nurse
assesses the child and noted 49 breaths per minute. The illness of the child can be classified as:
a. No pneumonia.
b. Pneumonia.
c. Severe pneumonia.
d. Very severe disease.
25. After 3 days, the nurse notes that James has chest in-drawing and stridor. His mother
returned him to the health center immediately. The nurse should:
a. Observe the child in the health center
b. Advice mother to observe the child and continue giving the antibiotics
c. Change the medicine to the second line antibiotics
d. Give first dose of antibiotics and refer urgently
IMCI SYMPTOM: DIARRHEA
26. An 8-month old infant was brought by his mother to the health center because of diarrhea
occurring 4 to 5 times a day. His skin goes back slowly after a skin pinch and his eyes are
sunken. Using the IMCI guidelines, you will classify this infant in which category?
a. The data is insufficient
b. Severe dehydration
c. Some dehydration
d. No signs of dehydration
27. For how many days are you going to treat with antibiotic a child with diarrhea and blood in
the stool?
a. 3 days
b. 5 days
c. 7 days
d. 14 days
28. Bibo, age 3, has had diarrhea for 10 days and is lethargic. He has sunken eyeballs but has no
blood in his stools. He drinks poorly when offered liquid. Skin pinch at the abdomen shows very
slow return. Using Integrated Management of Childhood Illness (IMCI), Bibos illness maybe
classified as:
a. Some dehydration
b. Severe dehydration
c. Persistent diarrhea

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d. No dehydration
29. Which of the following treatments should be immediately considered in Bibos case?
a. Continue feeding
b. Give 900 1,400 ORS during the first four hours
c. Explain to the mother how to prepare ORS
d. Reassess the child every 1-2 hours
30. Which of the following should not be given to children with diarrhea under the plan A
treatment of IMCI?
a. give extra fluid as much as the child wants
b. give the child 900 1,400 ml of ORS within 4 hours
c. give the child ORS, water and food based fluids like soup, rice water
d. if the child is exclusively breast fed, give ORS or clean water in addition to breast milk
31. Plan C treatment for dehydration includes:
a. Extra fluids, supplemental fluids and when to return
b. Give ORS and teach 4 home rules
c. IVF or NGT if IVF not available
d. All of these options
32. When assessing for signs of dehydration, the nurse should assess:
a. Level of consciousness
b. Skin turgor
c. Reaction of the child when offered drink
d. All of these options
33. As a nurse you must remember that any child with diarrhea, who has no general danger
signs and classified to have no dehydration, no anemia and not very low weight, may be given at
least 2 packets of ORS to use at home. You may also encourage the mother to give the following
to drink as long as diarrhea continues, EXCEPT:
a. water
b. fruit juice and buko juice
c. ORS after each loose stool
d. tea that the child usually drinks
34. While assessing an 8-month-old infant who has diarrhea, you noted that the diarrhea has
been for 2 days without presence of blood. The child kept playing with her rattle while sitting on
her mothers lap. The patients eyes were not sunken. When offered milk, the baby greedily
drank from the feeding bottle. What other symptom will you look into before you classify the
patients diarrhea?
a. skin turgor
b. pallor of palm
c. dryness of mouth
d. capillary refill
35. The child with no dehydration needs home treatment. Which of the following is NOT included
in the care for home management at this case?
a. Continue feeding the child
b. Inform when to return to the health center
c. Give drugs every 4 hours

135
d. Give child more fluids
36. You are taking care of an 8-month-old infant taken to the health center because of diarrhea
and fever. The mother reported that the baby had an episode of fever. The baby had no general
danger signs. The baby had no cough. The mother reported that the baby had diarrhea for 15
days, with some tinge of blood. The baby was quite restless during the assessment. When
offered milk, she drank eagerly and skin pinch went back briskly. When you took the temperature
of the baby the temperature was 37.30C. They do not live in a malaria or dengue endemic area.
The baby had no generalized rash. From your assessment, the nurse knows that:
a. the client needs urgent referral with no additional interventions
b. the client has to be treated with plan B for dehydration on the way to the hospital
c. the client has three classification for diarrhea and no other classification
d. the client can be treated in the health center
37. Mommy Ora is using Oresol in the management of diarrhea of her 3-year old child. She asked
you what to do if her child vomits. As a nurse you will tell her to:
a. Let the child rest for 10 minutes then continue giving Oresol more slowly.
b. Bring the child to the nearest hospital for further assessment.
c. Bring the child to the health center for assessment by the physician.
d. Bring the child to the health center for intravenous fluid therapy.
38. In teaching the mother of a 2 week old infant how to ensure proper attachment, the nurse
would have the mother do all of the following EXCEPT:
a. after stimulating infant, wait until infants mouth is wide open then move infant quickly to
breast
b. proper positioning technique is used
c. touch infants lips with her finger
d. aim the infants lower lip well below the nipple
IMCI SYMPTOM: FEVER
39. A mother reported that her 4-month-old baby is having fever for two days already.
babys temperature is 37.3C. The patient lives in Manila and has never traveled elsewhere.
did not have measles for the past 3 months and has not developed any generalized rash.
baby has a cough for 3 days already. What other information would be necessary before
decide on the patients classification?

The
She
The
you

a. episodes of high grade fever

b. episodes of diarrhea
c. presence of pus draining from the eyes
d. presence of signs of bleeding
40. In IMCI, there is fever when:
a. The mother reports a history of fever
b. The patient feels hot to touch
c. All of the above are true
d. None of the above
41. You have a 1-year-old patient coming in with fever of 38C lasting for eight days. The patient
lives in a malaria endemic area, manifests with runny nose and generalized rash with no signs of
bleeding. What will be one of the actions of the nurse?
a. conduct tourniquet test
b. classify the client

136
c. if possible, have a malaria smear done
d. refer immediately
42. Which of the following treatment should not be considered if the child has severe dengue
hemorrhagic fever?
a. Give Aspirin
b. Prevent low blood sugar
c. Use plan C if there is bleeding from the nose or gums
d. Give ORS if there is skin petechiae, persistent vomiting and positive tourniquet test
43. The child presents with mouth ulcer, what is the treatment regimen for this complaint?
a. Drink calamansi juice
b. Paint with Gentian violet
c. Gargle with guava leaves
d. Spray with tamarind sap
44. The first box in the 3 parts of fever protocol include:
a. Complications of measles
b. Risk of malaria categories
c. How to assess child with malaria, measles and meningitis
d. How to assess for DHN
45. A child has measles now, or within the last 3 months, the nurse should look for the following
signs:
a. Extensive mouth ulcers
b. Generalized rash
c. Pus draining from the eye
d. All the above
46. A 2-year-old girl is classified as having severe complicated measles when the following are
seen:
a. Deep ,extensive mouth ulcers
b. Clouding of the cornea
c. Pus draining from eyes
d. A and B only
47. This is a test used to determine, whether a child suspected with severe Dengue Hemorrhagic
Fever has circulatory problems:
a. Capillary refill time
b. Abdominal skin problems
c. Torniquet test
d. All of the above
48. A child is suspected of Dengue Hemorrhagic fever is positive for tourniquet test when:
a. There are 20 or more petechiae in one inch square just below the cuff
b. There are 20 or more petechiae in a 1.5 inch square above the cuff
c. There are 10 or more petechiae in one inch square just below the cuff
d. A and B
IMCI SYMPTOM: EAR PROBLEM

137
49. A child with ear problem should be assessed for the following, EXCEPT:
a. Ear discharge
b. Ear pain
c. Is there any fever?
d. If discharge is present how long?
50. An ear discharge that had been present for more than 14 days can be classified as:
a. Complicated ear infection
b. Mastoiditis
c. Acute ear infection
d. Chronic ear infection
51. An ear discharge that has been present for less than 14 days can be classified as:
a. Complicated ear infection
b. Mastoiditis
c. Acute ear infection
d. Chronic ear infection
52. If the child has severe classification because of ear problem, what would be the best thing
that you as the nurse can do?
a. Give antibiotics for 5 days
b. Instruct mother when to return immediately
c. Dry ear by wicking
d. Refer urgently
53. Lee Kutin, age 3, was brought by her mother to the center because of constant rubbing
behind the ear. The manifestation of Lee Kutin can be classified under
a. Ear drainage
b. Mastoiditis
c. Acute ear infection
d. Chronic ear infection
54. What would be the management for a patient with pus draining from the ear in a community
set up?
a. Suction the pus using an asepto syringe
b. Dry ear through wicking
c. Suction the pus using a straw
d. Through positioning
55. If the child does not have ear problem, using IMCI, what should you as the nurse do?
a. Check for tender swelling behind the ear
b. Go to the next question, check for malnutrition
c. Check for ear pain
d. Check for ear discharge
IMCI SYMPTOM: MALNUTRITION AND ANEMIA
56. A child presents with severe wasting as seen by the nurse and thorough assessment
revealed severe palmar pallor, these are classified under:
a. Malnutrition/severe anemia

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b. Some malnutrition/some anemia
c. Moderate malnutrition/severe anemia
d. Severe malnutrition/severe anemia
57. A child with some palmar pallor can be classified as:
a. Severe malnutrition/anemia
b. Anemia/very low weight
c. Moderate anemia/normal weight
d. Not very low weight/no anemia
58. Nina Payatot, age 4, has very low weight for age but with no other classification. The nurse
should intruct the mother of Nina for up in:
a. No more follow up is necessary
b. 30 days
c. 10 days
d. none of the above
59. A 4-year-old child is classified as having anemia and very low weight.
a. Give Mebendazole
b. Give Vitamin A
c. Both are not true for the classification
d. Both are true
60. A 3-month-old baby came in to your health center. She weighs 3 kgs. has a cough for 3 days
and when you assessed, had an RR of 48/min, negative for chest in-drawing and stridor. The
baby had no other problems. You assessed the babys nutritional status. You noted that she did
not have palmar pallor nor did she have signs of visible wasting or edema. Her weight is just
slightly below the lower cut-off for her age. Your assessment reveals:
a. patient can be classified as pneumonia
b. patient can be classified to green classification
c. patient can be classified as severe pneumonia; very severe disease
d. patient can be classified as very low weight

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ANSWERS AND CONCEPT ILLUMINATIONS

140
1. ANSWER: A.
CONCEPT ILLUMINATION
The primary objective of Integrated Management of Childhood Illness (IMCI) is to reduce the
morbidity and mortality among children by identifying the existing manifestations, classifying
them, and give appropriate treatment or referral to prevent complications. Option B is incorrect
because the disease is the one classified, and the treatment is identified. Health promotion is the
primary responsibility of the nurse in the community and not specific only for Integrated
Management of Childhood Illness (IMCI). Targetting fully immunized children is the objective of
Expanded Program on Immunization.
2. ANSWER: D.
CONCEPT ILLUMINATION
A combination of individual signs leads to a childs classification rather than a diagnosis. The
classification indicates the severity of condition.
3. ANSWER: B.
CONCEPT ILLUMINATION
The process employed in Integrated Management of Childhood Illness (IMCI) follows the order of
1. Assessing the child
2. Classifying the illness
3. Identifying treatment
4. Counseling the mother
5. Giving follow up care
4. ANSWER: C.
CONCEPT ILLUMINATION
In Integrated Management of Childhood Illness (IMCI), the sick child being evaluated using the
chart are children ages 2 months to 5 years old.
5. ANSWER: D.
CONCEPT ILLUMINATION
To effectively manage childhood illness, color-coded system has been utilized. The color-coded
system is used to classy the patient, identify the appropriate treatment for the classified
condition, and prioritize care.
6. ANSWER: C.
CONCEPT ILLUMINATION
When the mother arrives, the mother should be askes about the childs problem and if the visit is
initial or follow-up. If it is an initial visit, the nurse should assess the child and classify the
findings based on the chart. If it is for follow up visit, teh nurse should use the follow up
instructions on the Treat the Child chart.
7. ANSWER: D.
CONCEPT ILLUMINATION
All of the statements emphasize that the child is under the pink classification. Option A describes
severe dehydration in the pink box, that when given the plan C treatment, referral is no longer
necessary. Option B and C describes a child that needs urgent referral after being assessed with
general danger signs and given with appropriate antibiotics.
8. ANSWER: A.
CONCEPT ILLUMINATION
Children in the pink classification should be given first with the first dose of appropriate
antibiotics before sending the child to the hospital. Vitamin A is given not specifically in the pink
box only. Some classfication in the yellow and green box also receive Vitamin A. An intergrated
need not to be developed because the chart already explains the plan and interventions for each
classification.
9. ANSWER: C.

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CONCEPT ILLUMINATION
Cough or difficulty of breathing is a main symptom and is not included in checking the general
danger signs. The rest of the options should be asked prior to checking of general danger signs.
10. ANSWER: C.
CONCEPT ILLUMINATION
Severe dehydration does not always require urgent referral to the hospital because prior to
referral, the child can be treated in the center using:
1. Intravenous fluid therapy
2. Referral to a facility where IV fluids can be initiated within 30 minutes
3. Oresol via nasogastric tube or oral oresol
When the foregoing measures are not possible or effective, then urgent referral to the hospital is
done.
11. ANSWER: C.
CONCEPT ILLUMINATION
Mastoiditis is evidenced by tender swelling behind the ear under the pink classifica
tion of ear
problem. Pneumonia, some dehydration, and malaria all fall under the yellow classification.
12. ANSWER: C.
CONCEPT ILLUMINATION
Asking what is the childs problem is the very first step in the IMCI strategy. This opens up the
assessment process while establishing rapport at the same time. Next step is to determine if this
is an initial check up or a follow-up check up. If it is an initial check up you start assessment base
on the chart. If it is follow-up check up follow the instructions on the Treat the Child chart.
13. ANSWER: B.
CONCEPT ILLUMINATION
General danger signs include Convulsion, Unable to drink or breast-feed, Vomits everything, and
Abnormally sleepy. On the other hand, the four main symptoms are cough or difficult breathing,
diarrhea, fever, and ear problem. Fever is part of assessing the four main symptoms.
IMCI SYMPTOM: COUGH OR DIFFICULTY OF BREATHING
COLOR
Pink

SIGNS
Danger sign
Chest indrawing or
stridor

CLASSIFY AS
SEVERE
PNEUMONIA or
VERY SEVERE
DISEASE

Yellow

Fast breathing
1 week 2 mos
60 breaths/min or
more
2-12 mos
50 breaths/min or
more
12 mos 5 yrs
40 breaths/min or
more
No danger sign
No chest indrawing or
stridor
No fast berathing

PNEUMONIA

Green

NO
PNEUMONIA:
COUGH OR
COLD

TREATMENT
a. First dose of antibiotic (IM)
b. Vitamin A
6-12 mos 100,00 IU
12 mos-5 yrs 200,000 IU
c. Give sugar wateer
breastmilk or 200 ml water + 4 tsp
sugar
d. Refer urgently
a. Give antibiotic (oral)
First line Amoxicillin
Second line - Cotrimoxazole
b. Remedy for cough/soothe the
troat
Breastmilk
Tamarind, calamansi, ginger
c. Follow up in 2days
a. Remedy for cough/soothe the
troat
Breastmilk
Tamarind, calamansi, ginger
b. Advise mother when to return

142
immediately
c. Follow up
improving

in

5days

ALERT!
IF COUGHING more than
Indicates other diseases

if

not

30days-

14. ANSWER: C.
CONCEPT ILLUMINATION
A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or
more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally
sleepy or difficult to awaken.
15. ANSWER: B.
CONCEPT ILLUMINATION
To give appropriate and prompt treatment for pneumonia and other severe diseases so as to
prevent unnecessary deaths, the nurse is responsible in performing careful assessment. The
findings during the assessment will be the basis of the childs classification, and the classification
will determine the treatment necessary to prevent complication.
16. ANSWER: A.
CONCEPT ILLUMINATION
There is fast breathing if a child whose age is:
1 week to 2 months old infant have 60 or more breaths per minute
2 to 12 months old child have 50 or more breaths per minute
12 months to 5 years old child have 40 or more breaths per minute
17. ANSWER: A.
CONCEPT ILLUMINATION
In IMCI, the normal breath of an infant aged 2 to 12 months is less than 50 breaths per minute,
which in the situation is only 42/minute. If will only be considered fast breathing if it is 50 or
more breath per minute.
18. ANSWER: B.
CONCEPT ILLUMINATION
Presence of blood in the sputum is also respiratory but is not included in the assessment of
cough or difficulty of breathing. Cough is assessed with the guidelines based on its duration.
Difficulty of breathing is assessed using the presence of chest indrawing, and stridor or wheezes.
19. ANSWER: B.
CONCEPT ILLUMINATION
Chronic cough is characterized as cough for more than 30 days. The nurse should be alerted
because coughing with this duration could indicate other diseases aside from simple cough.
20. ANSWER: B.
CONCEPT ILLUMINATION
In IMCI, chest indrawing is used as the positive sign of dyspnea, indicating severe pneumonia.
COLOR
Pink

SIGNS
Danger sign
Chest indrawing or stridor

CLASSIFY AS
SEVERE PNEUMONIA or VERY
SEVERE DISEASE

21. ANSWER: C.
CONCEPT ILLUMINATION
Severe pneumonia requires urgent referral to a hospital. Answers A, C and D are done for a client
classified as having pneumonia.

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COLOR
Pink

CLASSIFY AS
SEVERE PNEUMONIA or VERY
SEVERE DISEASE

Yellow

PNEUMONIA

TREATMENT
a. First dose of antibiotic (IM)
b. Vitamin A
c. Give sugar wateer
d. Refer urgently
a. Give antibiotic (oral)
b. Remedy for cough/soothe the troat
c. Follow up in 2days

22. ANSWER: D.
CONCEPT ILLUMINATION
If chest indrawing or a general danger sign is present after 2 days of treatment, give a dose of
second-line antibiotic or intramuscular Benzyl Penicillin and Gentamicin. Then refer urgently to
hospital.
23. ANSWER: C.
CONCEPT ILLUMINATION
The child has chest in-drawing if the lower chest wall goes in when the child breathes in. It
occurs when the effort the child needs to breathe in is much greater than normal. For chest
indrawing to be present, it must be clearly visible and present all the time. If you only see chest
indrawing when the child is crying or feeding, the child does not have it.
24. ANSWER: B.
CONCEPT ILLUMINATION
Yellow

Fast breathing
1 week 2 mos 60 breaths/min or more
2-12 mos 50 breaths/min or more
12 mos 5 yrs 40 breaths/min or
more

PNEUMONIA

25. ANSWER: D.
CONCEPT ILLUMINATION
If chest indrawing or a general danger sign is present after 2 days of treatment, give a dose of
second-line antibiotic or intramuscular Benzyl Penicillin and Gentamicin. Then refer urgently to
hospital.
IMCI SYMPTOM: DIARRHEA
FOR DEHYDRATION
COLOR
SIGNS
Pink
Abnormally sleepy or
difficult to awaken
Unable to drink or drinking
poorly
Sunken eyes
Skin goes back VERY
SLOWLY

CLASSIFY AS
SEVERE
DEHYDRATIO
N

Yellow

Restless and irritable

Drinks eagerly or is thirsty
Sunken eyes
Skin pinch goes back
SLOWLY

SOME
DEHYDRATIO
N

Green

Not enough signs to classify

NO

TREATMENT
a. Plan C
b. Refer urgently if child has another
severe classification, with mother
giving frequent sips of ORS on the
way
c. If with cholera outbreak in the
area, give first dose of antibiotic
First line Tetracycline
Second line - Erythromycin
a. Plan B
b. Refer urgently if child has another
severe classification, with mother
giving frequent sips of ORS on the
way
c. Advise when to return
d. Follow up in 2 days
a. Plan A

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severe or some dehydration

FOR DIARRHEA
COLOR
SIGNS
Pink
Dehydration is present
Yellow

No dehydration

Yellow

Blood in the stool

DEHYDRATIO
N

Give extra fluids

Give Zinc
Continue feeding
Know when to return to the health
center
b. Give Zinc
c. Advise when to return
d. Follow up in 2 days

CLASSIFY AS
SEVERE
PERSISTENT
DIARRHEA
PERSISTENT
DIARRHEA

TREATMENT
a. Treat DHN before referral
b. Give Vitamin A
c. Refer to hospital
a. Vitamin A
b. Special feeding as explained in
counseling the mother
c. Follow up in 5days
a. Ciprofloxacin for 5 days
b. Follow up 2 days

DYSENTERY

26. ANSWER: C.
CONCEPT ILLUMINATION
Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is
classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or
irritable, sunken eyes, the skin goes back slow after a skin pinch.
Yellow

Restless and irritable

Drinks eagerly or is thirsty
Sunken eyes
Skin
pinch
goes
back
SLOWLY

SOME DEHYDRATION

27. ANSWER: B.
CONCEPT ILLUMINATION
Yellow

Blood in the stool

DYSENTERY

a. Ciprofloxacin for 5 days

b. Follow up 2 days

28. ANSWER: B.
CONCEPT ILLUMINATION
Pink

Abnormally sleepy or difficult to awaken

Unable to drink or drinking poorly
Sunken eyes
Skin goes back VERY SLOWLY

SEVERE DEHYDRATION

29. ANSWER: D.
CONCEPT ILLUMINATION
Pink

SEVERE DEHYDRATION

Plan C
1. Give IVF 100 ml/kg of LRS or NSS
2. Reassess every 1-2 hours. If hydration is not
improving, give IVF rapidly
3. Give ORS 5ml/kg/hour as soon as the child can
drink
4. Reasses after 6 hours for infant. Reassess after 3

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hours for child.
5. If IVF is not available wthin 30 mins NGT
30. ANSWER: B.
CONCEPT ILLUMINATION
Give the child 900 1,400 ml of ORS within 4 hours is under plan B and not plan A.
Plan A (Four Rules of Home Treatment)
Give extra fluids
a. breastmilk, add ORS or clean water for EXCLUSIVE BREASTFEEDING
b. soup, rice water, buko juice for NON- EXCLUSIVE BREASTFEEDING
Give Zinc
Continue feeding
Know when to return to the health
Plan B
Give ORS in the clinic
For non-breastfeeding infant below 6 months, give additional 100-200 ml of clean water
Reassess and classify after 4 hours
Rules of home treatment
31. ANSWER: C.
CONCEPT ILLUMINATION
Plan C
1. Give IVF 100 ml/kg of LRS or NSS
2. Reassess every 1-2 hours. If hydration is not improving, give IVF rapidly
3. Give ORS 5ml/kg/hour as soon as the child can drink
4. Reasses after 6 hours for infant. Reassess after 3 hours for child.
5. If IVF is not available wthin 30 mins NGT
32. ANSWER: D.
CONCEPT ILLUMINATION
In the assessment for the signs of dehydration, the guidelines include:
Level of consciousness If the child is abnormally sleepy or difficult to awaken or is restless or
irritable
Skin turgor if skin goes back very slowly or slowly only
Reaction of the child when offered a drink if unable to drink or drinking poorly, or drinks eagerly
33. ANSWER: D.
CONCEPT ILLUMINATION
In the list of home treatment, the child with diarrhea can be given extra fluids. Aside from
breastfeeding, the mother could give the child clear water, buko juice or any fruit juice, soup,
and ORS after each loose stool. Giving the child tea is not part of the home treatment.
34. ANSWER: A.
CONCEPT ILLUMINATION
The signs that should be assessed by the nurse when a child has diarrhea are the level of
consciousness, eye if sunken or not, and reaction of the child when offered a drink. Aside from
these 3 guidelines, the skin turgor of the child should be assessed, whether the skin, after
pinching, goes back slowly, or very slowly.
35. ANSWER: C.
CONCEPT ILLUMINATION
A child with no dehydration should no longer be given drugs, such as antibiotics, but rather Zinc
supplement. Food and fluid should also be given at home. Here is the treatment of No
Dehydration:
Plan A (Four Rules of Home Treatment)
Give extra fluids

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a. breastmilk, add ORS or clean water for EXCLUSIVE BREASTFEEDING
b. soup, rice water, buko juice for NON- EXCLUSIVE BREASTFEEDING
Give Zinc
Continue feeding
Know when to return to the health
36. ANSWER: B.
CONCEPT ILLUMINATION
Having tinge of blood in the stool indicates Dysentery and the other manifestations noted,
restlessness, drinks eagerly, and pinch went back briskly, indicate some dehydration. In the IMCI
chart, some dehydration is treated using Plan B. Urgent referral in option A is for severe
dehydration but the mother should offer fluids while on the way to the hospita. Option C will not
address the problem. Option D will only address some dehydration but not dysentery.
37. ANSWER: A.
CONCEPT ILLUMINATION
If the child vomits persistently, that is, he vomits everything that he takes in, he has to be
referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10
minutes and then continuing with Oresol administration. Teach the mother to give Oresol more
slowly.
38. ANSWER: C.
CONCEPT ILLUMINATION
To ensure proper attachment and stimulate breastfeeding, the mother should touch the side of
the infants lip. This is known as rooting reflex, so as the infant will locate the touched part until
the mouth reaches the breast of the mother.
IMCI SYMPTOM: FEVER
MALARIA RISK
COLOR
SIGNS
Pink
Danger sign, stiff
neck

Yellow

Green

(+) blood smear

If blood smear not
done:
No runny nose
No measles
NO other cause of
fever
(-) blood smear
Runny nose or
measles or
Other cause of fever

NO MALARIA RISK
COLOR
SIGNS
Pink
Danger
neck

Green

No

sign,

signs

of

stiff

very

CLASSIFY AS
VERY SEVERE
FEBRILE
DISEASE/MALARI
A

MALARIA

TREATMENT
a. First dose of anti-malarial drug
b. Give appropriate antibiotic
c. Treat to prevent low blood sugar
d. Paracetamol for fever more than
38.5C
e. Send blood smear with patient
f. Refer urgently
a. Oral anti-malarial
b. Paracetamol for fever more than
38.5C
c. Advise when to return
d. Follow up in 2 days if fever persists

FEVER: MALARIA
UNLIKELY

a. Paracetamol for fever more than

38.5C
b. Follow up in 2 days if fever persists
c. Treat other cause of fever

CLASSIFY AS
VERY SEVERE
FEBRILE
DISEASE

TREATMENT
a. Give appropriate antibiotic
b. Treat to prevent low blood sugar
c. Paracetamol for fever more than
38.5C
f. Refer urgently
a. Paracetamol for fever more than

FEVER: NO

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severe disease

MEASLES
COLOR
Pink

MALARIA

SIGNS
Clouding of cornea
Deep or extensive
mouth ulcers
Any danger sign

CLASSIFY AS
SEVERE
COMPLICATED
MEASLES

Yellow

Pus draining from the

eye
Mouth ulcers

MEASLES WITH
EYE OR MOUTH
COMPLICATIONS

Green

Measles now or
within the last 3
months

MEASLES

DENGUE HEMORRHAGIC FEVER

COLOR
SIGNS
CLASSIFY AS
Pink
Bleeding (nose,
SEVERE
gums, stools,
DENGUE
vomitus)
HEMORRHAGIC
Skin petechiae
FEVER
Cold clammy skin
Capillary refill >3 sec
Persistent abdominal
pain or vomiting
Positive Torniquet test
Green
No signs of severe
FEVER: DENGUE
Dengue hemorrhagic
HEMORRHAGIC
fever
FEVER
UNLIKELY

38.5C
b. Follow up in 2 days if fever persists
c. Treat other cause of fever
TREATMENT
a. Vitamin A
b. Appropriate antibiotic
c. Tetracycline eye ointment for
draining pus
d. Refer urgently
a. Vitamin A
b. Tetracycline eye ointment for
draining pus
c. Gential violet for mouth ulcers
d. Follow up 2 days
e. Advise when to retun
a. Vitamin A
b. Advise when to retun

TREATMENT
a. Plan B if with vomiting, abdominal
pain, skin petechiae, positive Torniquet
b. Plan C if with signs of bleeding
c. Treat low blood sugar
d. Refer urgently
e. Do not give aspirin

a. Advise when to return

b. Follow up 2 days if with signs of
bleeding
c. Do not give aspirin

39. ANSWER: D.
CONCEPT ILLUMINATION
The situation clearly states that the child is not malaria risk because the child has no history of
travel, not measle risk because there is no presence of rashes or measles for the last 3 months.
The next assessment of the nurse is to assess for signs of bleeding, which could indicate the
likelihood of Dengue Hemorrhagic fever.
40. ANSWER: C.
CONCEPT ILLUMINATION
All of the statements indicate fever. In the IMCI chart, the assessment of fever is based on the
following guidelines:
a. History of fever
b. Child feels hot
d. Temperature 7.5 C or higher
41. ANSWER: C.
CONCEPT ILLUMINATION
If the child manifest runny nose and generalized rashes, no signs of bleeding, and most
importantly, the child resides in a malaria risk area, the next step of the nurse should be to have
a blood smear for malaria. This will confirm if the patient is classified under Malaria or Fever:
Malaria Unlikely.

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Yellow
Green

(+) blood smear

(-) blood smear

MALARIA
FEVER: MALARIA UNLIKELY

42. ANSWER: A.
CONCEPT ILLUMINATION
Aspirin is an anti-platelet aggregate or a blood thinner, that when administered to a child with
Dengue Hemorrhagic Fever will cause further bleeding. The other options are included in the
treatment of Severe Dengue Hemorrhagic fever.
SEVERE DENGUE
HEMORRHAGIC FEVER

a. Plan B (ORS) if with vomiting, abdominal pain, skin

petechiae, positive Torniquet
b. Plan C if with signs of bleeding
c. Treat low blood sugar
d. Refer urgently
e. Do not give aspirin

43. ANSWER: B.
CONCEPT ILLUMINATION
For mouth ulcer, we paint the ulcer site with half strength Gentian violet. Calamansi juice is
acidic and will irritate the mouth ulcers. Gargling with guave leaves or spraying with tamarind
sap will also cause the same reaction.
44. ANSWER: C.
CONCEPT ILLUMINATION
Included in the 3 parts of fever protocol are the 3 Ms or the malaria, measles and meningitis.
45. ANSWER: D.
CONCEPT ILLUMINATION
If the child has measles now or within the last 3 months, the child should be classified based on
the other presenting signs aside from fever, which are extensive mouth ulcers, generalized rash,
and pus draining from the eye. After assessing the mentions manifestation, the nurse will then
classify the child.
Clouding of cornea
Deep or extensive mouth ulcers
Any danger sign
Pus draining from the eye
Mouth ulcers
Measles now or within the last 3 months

SEVERE COMPLICATED MEASLES

MEASLES WITH EYE OR MOUTH
COMPLICATIONS
MEASLES

46. ANSWER: D.
CONCEPT ILLUMINATION
Pus draining from the eyes is under the classification of Measles with eye or mouth
complications. The manifestations of severe complicated measles are:
Clouding of cornea
Deep or extensive mouth ulcers
Any danger sign

SEVERE COMPLICATED MEASLES

47. ANSWER: A.
CONCEPT ILLUMINATION
Circulatory problem in Dengue Hemorrhagic Fever can be best evaluated using the Blanch test or
the test for capillary refill time. The normal refill time after applying minimal pressure in the
nailbed is less than 3 seconds. The capillary refill time of severe dengue hemorrhagic fever is
more than 3 seconds. Abdominal skin is used to assess skin turgor of a child. Torniquet test
determines capillary fragility and bleeding.

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48. ANSWER: A.
CONCEPT ILLUMINATION
Torniquet test is performed to assess capillary fragility as a sign of bleeding in Dengue
hemorrhagic fever. Pposition torniquet test is characterized by 20 or more petechiae in one inch
square just below the BP cuff used.
IMCI SYMPTOM: EAR PROBLEM
COLOR
Pink

SIGNS
Tender swelling behind
the ear

CLASSIFY AS
MASTOIDITIS

Yellow

Ear pain
Ear discharge less than
14 days

ACUTE EAR
INFECTION

Yellow

Ear discharge more than

14 days

CHRONIC EAR
INFECTION

Green

No ear pain
No ear discharge

NO EAR INFECTION

TREATMENT
a. Oral antibiotic
b. Paracetamol for pain
c. Refer urgently
a. Antibiotic for 5 days
b. Paracetamol for pain
c. Dry ear by wicking
d. Follow up 5 days
e. Advise when to return
a. Dry ear by wicking
b. Follow up 5 days
c. Advise when to return
a. Advise when to return
No additional treatment

49. ANSWER: C.
CONCEPT ILLUMINATION
When classifying ear problem, the nurse should look for Ear pain, ear discharge such as pus
draining from the ear, how long the discharge, or if with tender swelling behind the ear. Fever is
not one of the signs to assess when dealing with ear problems.
50. ANSWER: D.
CONCEPT ILLUMINATION
Yellow
Yellow

Ear discharge less than 14

days
Ear discharge more than 14
days

ACUTE EAR INFECTION

CHRONIC EAR INFECTION

51. ANSWER: C.
CONCEPT ILLUMINATION
Yellow
Yellow

Ear discharge less than 14

days
Ear discharge more than 14
days

ACUTE EAR INFECTION

CHRONIC EAR INFECTION

52. ANSWER: D.
CONCEPT ILLUMINATION
Severe classification of ear problem means Mastoiditis.giving antibiotics, advising mother when
to return, and drying the ear by wicking are treatment for acute ear infection.
Pink

Tender swelling behind

the ear

MASTOIDITIS

a. Oral antibiotic
b. Paracetamol for pain
c. Refer urgently

53. ANSWER: B.
CONCEPT ILLUMINATION
Mastoiditis is inflammation of the mastoid bone as evidenced by tender swelling behind the ear.
The most common behavior being manifested is constant rubbing behind the ear.

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54. ANSWER: B.
CONCEPT ILLUMINATION
Pus draining from the ear is best managed by drying the ear by wicking through the use of a
strong tissue wrapped around a wick to absorb the pus until no longer draining.
55. ANSWER: B.
CONCEPT ILLUMINATION
The next item after the ear problems are focused on malnutrition. If ear problem is not present
on the child, the nuse should go to the next question and check for malnutrition.
IMCI SYMPTOM: MALNUTRITION AND ANEMIA
COLOR
Pink

SIGNS
Visible severe wasting
Edema of both feet
Severe palmar pallor

Yellow

Some palmar pallor

Very low weight for
age

CLASSIFY AS
SEVERE
MALNUTRITION
OR SEVERE
ANEMIA
ANEMIA OR
VERY LOW
WEIGHT

Green

Not very low weight

for age, and no other
signs of malnutrition

NO ANEMIA
AND NOT VERY
LOW WEIGHT

TREATMENT
a. Vitamin A
b. Refer urgently
a. Assess feeding If with problem,
follow up 5 days
b. Some palmar pallor
Iron
Mebendazole if 12 months and
above
Mebendazole if no dose 6
months ago
c. Very low weight
Vitamin A
Follow up 30 days
d. Advise when to return
a. Assess feeding If with problem,
follow up 5 days
b. Advise when to return

56. ANSWER: D.
CONCEPT ILLUMINATION
Pink

Visible severe wasting, Edema of both

feet
Severe palmar pallor

SEVERE MALNUTRITION OR
SEVERE ANEMIA

57. ANSWER: B.
CONCEPT ILLUMINATION
Yellow

Some palmar pallor, Very low weight for

age

ANEMIA OR VERY LOW WEIGHT

58. ANSWER: B.
CONCEPT ILLUMINATION
Yellow

Some palmar pallor

Very low weight for
age

ANEMIA OR VERY
LOW WEIGHT

Very low weight:

Vitamin A
Follow up 30 days

59. ANSWER: D.
CONCEPT ILLUMINATION
Yellow

ANEMIA OR VERY LOW

a. Assess feeding If with problem, follow up 5 days

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WEIGHT

b. Some palmar pallor

Iron
Mebendazole if 12 months and above
Mebendazole if no dose 6 months ago
c. Very low weight
Vitamin A
Follow up 30 days
d. Advise when to return

60. ANSWER: D.
CONCEPT ILLUMINATION
The child has no symptom under the classification of cough or difficulty of breathing, because
the RR is normal and negative for chest in-drawing and stridor. The only manifestation is very
low weight for age, making the child a candidate for the classification of malnutrition under the
yellow classification of Very Low Weight for Age.

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