Question 1

The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences?
A) The parent feels inferior to the nurse.
B) The parent is showing respect for the nurse.
C) The parent is embarrassed to seek health care.
D) The parent feels responsible for her child's illness.

Accepted Answer

In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurse's eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse.

Question 2

The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.)
A) Wheezes
B) Crackles
C) Vesicular
D) Bronchial
E) Bronchovesicular

Accepted Answer

Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds.

Question 3

The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)
A) Ashen gray areas
B) A well-defined light reflex
C) A small, round, concave spot near the center of the drum
D) The tympanic membrane is a nontransparent grayish color
E) A whitish line extending from the umbo upward to the margin of the membrane

Accepted Answer

Normal findings include the light reflex and bony landmarks. The light reflex is a fairly well-defined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation.

Question 4

The nurse is aware that skin turgor best estimates what?
A) Perfusion
B) Adequate hydration
C) Amount of body fat
D) Amount of anemia

Accepted Answer

Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia.

Question 5

The nurse understands that blocks to therapeutic communication include what? (Select all that apply.)
A) Socializing
B) Use of silence
C) Using clichés
D) Defending a situation
E) Using open-ended questions

Accepted Answer

Blocks to communication include socializing, using clichés, and defending a situation. Use of silence and using open-ended questions are therapeutic communication techniques.

Question 6

The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.)
A) S4 heart sound
B) S3 heart sound
C) Grade II murmur
D) S1 louder at the apex of the heart
E) S2 louder than S1 in the aortic area

Accepted Answer

S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area.

Question 7

The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)
A) Lightly brush the palate with a cotton swab.
B) Perform the examination in front of a mirror.
C) Let the child examine someone else's mouth first.
D) Have the child breathe deeply and hold his or her breath.
E) Use a tongue blade to help the child open his or her mouth.

Accepted Answer

To encourage a child to open the mouth for examination, the nurse can lightly brush the palate with a cotton swab, perform the examination in front of a mirror, let the child examine someone else's mouth first, and have the child breathe deeply and hold his or her breath. A tongue blade may elicit the gag reflex and should not be used.

Question 8

Which are effective auscultation techniques? (Select all that apply.)
A) Ask the child to breathe shallowly.
B) Apply light pressure on the chest piece.
C) Use a symmetric and orderly approach.
D) Place the stethoscope over one layer of clothing.
E) Warm the stethoscope before placing it on the skin.

Accepted Answer

Effective auscultation techniques include using a symmetric approach and warming the stethoscope before placing it on the skin. Breath sounds are best heard if the child inspires deeply, not shallowly. Firm, not light, pressure should be used on the chest piece. The stethoscope should be placed on the skin, not over clothing.

Question 9

Which action should the nurse implement when taking an axillary temperature?
A) Take the temperature through one layer of clothing.
B) Add a degree to the result when recording the temperature.
C) Place the tip of the thermometer under the arm in the center of the axilla.
D) Hold the child's arm away from the body while taking the temperature.

Accepted Answer

The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The child's arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method.

Quiz 4: Communication, Physical, and Developmental Assessment

The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences?

The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.)

The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)

The nurse is aware that skin turgor best estimates what?

The nurse understands that blocks to therapeutic communication include what? (Select all that apply.)

The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.)

The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

Which are effective auscultation techniques? (Select all that apply.)

Which action should the nurse implement when taking an axillary temperature?