Question 1

The nurse must assess 10-month-old infant.The infant is sitting on the father's lap and appears to be afraid of the nurse and of what may happen next.Which initial action by the nurse would be most appropriate?

Accepted Answer

Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe,nonthreatening distance.The child will most likely become upset if separated from his father.As much of the assessment as possible should be done while the child is on the father's lap.The nurse should have the father undress the child as needed for the examination.

Question 2

The appropriate placement of a tongue blade for assessment of the mouth and throat is the:

Accepted Answer

The side of the tongue is the correct position.It avoids the gag reflex yet allows visualization.Placement on the center back area of the tongue elicits the gag reflex.Against the soft palate and on the lower jaw are not appropriate places for the tongue blade.

Question 3

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change.The nurse decides to do a simple magic trick using gauze.This should be interpreted as:

Accepted Answer

A magic trick or other simple game may help alleviate anxiety for a 5-year-old.It is an excellent method to build rapport and facilitate cooperation during a procedure.Magic tricks appeal to the natural curiosity of young children.The nurse should establish rapport with the child.Failure to do so may cause the procedure to take longer and be more traumatic.

Question 4

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?

Accepted Answer

Vesicular breath sounds are heard over the entire surface of lungs,with the exception of the upper intrascapular area and the area beneath the manubrium.Bronchial breath sounds are heard only over the trachea near the suprasternal notch.Adventitious breath sounds are not usually heard over the chest.These sounds occur in addition to normal or abnormal breath sounds.Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate.

Question 5

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

Accepted Answer

Lateral bowing of the tibia (bowlegged)is common in toddlers when they begin to walk,not an abnormal finding.It usually persists until all of their lower back and leg muscles are well developed.Further evaluation is needed if it persists beyond ages 2 to 3 years,especially in African-American children.

Question 6

The most frequently used test for measuring visual acuity is the:

Accepted Answer

The Snellen letter chart,which consists of lines of letters of decreasing size,is the most frequently used test for visual acuity.Single cards (Denver-letter E; Allen-pictures)are used for children age 2 years and older who are unable to use the Snellen letter chart.The Ishihara vision test is used for color vision.

Question 7

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

Accepted Answer

A brilliant,uniform red reflex is an important normal and expected finding.It rules out many serious defects of the cornea,aqueous chamber,lens,and vitreous chamber.

Question 8

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

Accepted Answer

Petechiae,small distinct pinpoint hemorrhages,are difficult to see in dark skin unless they are in the mouth or conjunctiva.

Question 9

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

Accepted Answer

Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood.S? is the closure of the tricuspid and mitral valves,and S? is the closure of the pulmonic and aortic valves,and both are considered normal heart sounds.S? is a normal heart sound sometimes heard in children.S? is rarely heard as a normal heart sound.If heard,medical evaluation is required.Physiologic splitting is the distinction of the two sounds in S?,which widens on inspiration.It is a significant normal finding.

Question 10

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

Accepted Answer

Binocularity is usually achieved by ages 3 to 4 months.Age 1 month is too young for binocularity.If binocularity is not achieved by 6 months,the child must be observed for strabismus.

Question 11

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

Accepted Answer

Visual fixation and following a target should be present by ages 3 to 4 months.Ages 1 to 2 months are too young for this developmental milestone.If the infant is not able to fix and follow by 6 months of age,further ophthalmologic evaluation is needed.

Question 12

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

Accepted Answer

Small nontender nodes are normal.Tender,enlarged,and warm lymph nodes may indicate infection or inflammation close to their location.Tender lymph nodes do not usually indicate cancer.A scalp infection usually does not cause inflamed lymph nodes.The lymph nodes close to the site of inflammation or infection would be inflamed.

Question 13

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

Accepted Answer

Head circumference begins larger than chest circumference.Between ages 1 and 2 years,they become approximately equal.Head circumference is larger than chest circumference at ages 1 month and 6 to 9 months.Chest circumference is larger than head circumference at age 2.5 to 3 years.

Question 14

The earliest age at which a satisfactory radial pulse can be taken in children is:

Accepted Answer

Satisfactory radial pulses can be used in children older than 2 years.In infants and young children the apical pulse is more reliable.The radial pulse can be used for assessment at ages 3 and 6 years.

Question 15

The nurse should expect the anterior fontanel to close at age:

Accepted Answer

Ages 2 through 8 months are too early.The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes at these earlier ages,the child should be referred for further evaluation.

Question 16

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.The most appropriate action is to:

Accepted Answer

These symptoms indicate meningeal irritation and need immediate evaluation.Continuing the assessment is not necessary.No indication of injury is present.This is not descriptive of head lag.

Question 17

The nurse must assess a child's capillary filling time.This can be accomplished by:

Accepted Answer

Capillary filling time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill.Inspecting the chest,auscultating the heart,and palpating the apical pulse will not provide an assessment of capillary filling time.

Question 18

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

Accepted Answer

Wheezes are produced as air passes through narrowed passageways.The sound is similar when the narrowing is caused by exudates,inflammation,spasm,or tumor.Rubs are the sound created by the friction of one surface rubbing over another.Pleural friction rub is caused by inflammation of the pleural space.Rattles is the term formerly used for crackles.Crackles are the sounds made when air passes through fluid or moisture.

Question 19

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

Accepted Answer

The finger-to-nose-test is an indication of cerebellar function.This test checks balance and coordination.Each deep tendon reflex is tested separately.Each sense is tested separately.Although this test enables the nurse to evaluate the child's ability to follow directions,it is used primarily for cerebellar function.

Question 20

The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes.The rationale for this position is that:

Accepted Answer

The tailor position stretches the muscle responsible for the cremasteric reflex.This prevents its contraction,which pulls the testes into the pelvic cavity.Undescended testes cannot be predictably palpated.Inguinal hernias are not detected by this method.This position is used for inhibiting the cremasteric reflex.Privacy should always be provided for children.

Quiz 29: Communication, history, and Physical Assessment