Deck 7: Physical and Developmental Assessment of the Child

Question 1

Which of the following is an appropriate approach to performing a physical assessment on a toddler?

A)Always proceed in a head-to-toe direction.
B)Perform traumatic procedures first.
C)Use minimal physical contact initially.
D)Demonstrate use of equipment.

Answer 1

Use minimal physical contact initially.

Question 2

Pulses can be graded according to certain criteria. Which of the following is a description of a normal pulse?

A)0
B)+1
C)+2
D)+3

Answer 2

+3

Question 3

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

A)Face
B)Buttocks
C)Oral mucosa
D)Palms and soles

Answer 3

Oral mucosa

Question 4

Rectal temperatures are indicated in which of the following situations?

A)In the newborn period
B)Whenever accuracy is essential
C)When no other route or device can be used
D)When rapid temperature changes are occurring

Question 5

Which of the following would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?

A)Axillary sensor
B)Tympanic membrane sensor
C)Rectal mercury glass thermometer
D)Rectal electronic thermometer

Question 6

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?

A)Some form of cancer
B)Local scalp infection common in children
C)Infection or inflammation distal to the site
D)Infection or inflammation close to the site

Question 7

The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. This action should be considered which of the following?

A)Appropriate, because of child's age
B)Appropriate, because mother would be uncomfortable making decision for child
C)Inappropriate, because of child's age
D)Inappropriate, because child is same sex as mother

Question 8

With the National Center for Health Statistics (NCHS) criteria, which one of the following body mass index (BMI)-for-age percentiles would be at risk for overweight?

A)10^th percentile
B)9^th percentile
C)85^th percentile
D)95^th percentile

Question 9

Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age?

A)1 month
B)3 to 4 months
C)6 to 8 months
D)12 months

Question 10

During a routine health assessment, the nurse notes that the 8-month-old infant has a significant head lag. Which of the following is the nurse's most appropriate action?

A)Teach parents appropriate exercises.
B)Recheck head control at next visit.
C)Refer child for further evaluation.
D)Refer child for further evaluation if anterior fontanel is still open.

Question 11

The nurse is using calipers to measure skin-fold thickness over the triceps muscle in a school-age child. What is the purpose of doing this?

A)To measure body fat
B)To measure muscle mass
C)To determine arm circumference
D)To determine accuracy of weight measurement

Question 12

The purpose of the random-dot-E stero test is to assess for:

A)Red reflex.
B)Visual acuity.
C)Fovea centralis.
D)Depth perception.

Question 13

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which of the following is the most appropriate action?

A)Refer for immediate medical evaluation.
B)Continue assessment to determine cause of neck pain.
C)Ask parent when neck was injured.
D)Record "head lag" on assessment record, and continue assessment of child.

Question 14

The nurse is using the NCHS growth chart for an African-American child. Which of the following should the nurse consider?

A)This growth chart should not be used.
B)Growth patterns of African-American children are the same as for all other ethnic groups.
C)A correction factor is necessary when the NCHS growth chart is used for nonwhite ethnic groups.
D)The NCHS charts are accurate for United States African-American children.

Question 15

Which one of the following tools measures body fat most accurately?

A)Stadiometer
B)Calipers
C)Cloth tape measure
D)Paper or metal tape measure

Question 16

By what age do the head and chest circumferences generally become equal?

A)1 month
B)6 to 9 months
C)1 to 2 years
D)2 1/2 to 3 years

Question 17

The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. This should be interpreted as:

A)Normal.
B)Erythema.
C)Jaundice.
D)Ecchymosis.

Question 18

At what age should the nurse expect the anterior fontanel to close?

A)2 months
B)2 to 4 months
C)6 to 8 months
D)12 to 18 months

Question 19

What is the earliest age at which a satisfactory radial pulse can be taken in children?

A)1 year
B)2 years
C)3 years
D)6 years

Question 20

During a funduscopic examination of a school-age child, the nurse notes presence of a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which of the following?

A)Normal finding
B)Abnormal finding, so child needs referral to ophthalmologist
C)Sign of possible visual defect, so child needs vision screening
D)Sign of small hemorrhages, which will usually resolve spontaneously

Question 21

The nurse is administering the Denver II to a 16-week-old infant who was born 4 weeks early. At what age should the infant be tested?

A)10 weeks
B)12 weeks
C)16 weeks
D)18 weeks

Question 22

An appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child is which of the following?

A)Rinne test
B)Weber test
C)Conventional audiometry
D)Eliciting the startle reflex

Question 23

The nurse has determined the rate of both the child's radial pulse and heart. When comparing the two rates, the nurse should expect that normally they:

A)Are the same.
B)Differ, with heart rate faster.
C)Differ, with radial pulse faster.
D)Differ, depending on quality and intensity.

Question 24

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for which of the following?

A)Deep tendon reflexes
B)Cerebellar function
C)Sensory discrimination
D)Ability to follow directions

Question 25

While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What is this pattern of respiration called?

A)Dyspnea
B)Tachypnea
C)Cheyne-Stokes respirations
D)Seesaw (paradoxic) respirations

Question 26

When auscultating an infant's lungs, the nurse detects diminished breath sounds. The nurse should interpret this as which of the following?

A)Suggestive of chronic pulmonary disease
B)Suggestive of impending respiratory failure
C)An abnormal finding warranting investigation
D)A normal finding in infants younger than 1 year

Question 27

During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which of the following?

A)Abnormal and requires further investigation
B)Abnormal unless it occurs in conjunction with knock-knee
C)Normal if the condition is unilateral or asymmetric
D)Normal because the lower back and leg muscles are not yet well developed

Question 28

What term is used to describe breath sounds that are produced as air passes through narrowed passageways?

A)Rubs
B)Rattles
C)Wheezes
D)Crackles

Question 29

Examination of the abdomen is performed correctly by the nurse in the following order:

A)Inspection, palpation, and auscultation
B)Palpation, inspection, and auscultation
C)Palpation, auscultation, and inspection
D)Inspection, auscultation, and palpation

Question 30

Which of the following is the most appropriate vision acuity test for a child who is in preschool?

A)Cover test
B)Ishihara test
C)HOTV chart
D)Snellen letter chart

Question 31

The nurse is beginning to administer the Denver II to a small child when his mother says, "Can you tell me again what this Denver II is?" The nurse's best response is which of the following?

A)"It's a simple intelligence test of young children."
B)"It tells us what a child can do at a particular age."
C)"It's a test we give to measure a child's development."
D)"It's an excellent way to see if a child's development is normal."

Question 32

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?

A)1 month
B)1 to 2 months
C)3 to 4 months
D)6 months

Question 33

What type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

A)Vesicular
B)Bronchial
C)Adventitious
D)Bronchovesicular

Question 34

The nurse has a 2-year-old boy sit in "tailor" position while palpating for the presence of the testes. What is the rationale for this position?

A)It prevents cremasteric reflex.
B)Undescended testes can be palpated.
C)This tests the child for an inguinal hernia.
D)Child does not yet have a need for privacy.

Question 35

At about what age does the Babinski sign disappear?

A)4 months
B)6 months
C)1 year
D)2 years

Question 36

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

A)S_l, S₂
B)S₃, S₄
C)Murmur
D)Physiologic splitting

Question 37

What is the most frequently used test for measuring visual acuity?

A)Denver Eye Screening Test
B)Allen Picture Card Test
C)Ishihara's Vision Test
D)Snellen Letter Chart

Question 38

The nurse must do vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Select all the criteria the nurse should use in determining the appropriate-size blood pressure cuff.

A)The cuff is labeled "toddler"
B)The cuff bladder width is approximately 40% of the circumference of the upper arm.
C)The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
D)The cuff bladder covers 50% to 66% of the length of the upper arm.

Question 39

The appropriate placement of a tongue blade for assessment of the mouth and throat is which of the following?

A)Center back area of tongue
B)Side of the tongue
C)Against the soft palate
D)On the lower jaw

Question 40

The nurse must assess a child's capillary filling time. This can be accomplished by doing which of the following?

A)Inspect the chest.
B)Auscultate the heart.
C)Palpate the apical pulse.
D)Palpate the skin to produce a slight blanching.