Deck 33: Physical Assessment of Children

Question 1

The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or violet color.This skin coloration is associated with what?

A) Cyanosis
B) Erythema
C) Vitiligo
D) Nevi

Answer 1

Erythema

Question 2

A nurse is reviewing pediatric physical assessment techniques.Which statement about performing a pediatric physical assessment is correct?

A) Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise.
B) The physical examination should be done with parents in the examining room for children of any age.
C) Measurement of head circumference is done until the child is 5 years old.
D) The physical examination is done only when the child is cooperative.

Answer 2

Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise.

Question 3

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones.This should be considered

A) unnecessary information, because the child is 3 years old.
B) an important part of the family history.
C) an important part of the child's past growth and development.
D) an important part of the child's review of systems.

Answer 3

an important part of the child's past growth and development.

Question 4

Which strategy is the best approach when initiating the physical examination of a 9-month-old male infant?

A) Undress the infant and do a head-to-toe examination.
B) Have the parent hold the child on his or her lap.
C) Put the infant on the examination table and begin assessments at the head.
D) Ask the parent to leave because the infant will be upset.

Question 5

Which chart should the nurse use to assess the visual acuity of an 8-year-old child?

A) Lea chart
B) Snellen chart
C) HOTV chart
D) Tumbling E chart

Question 6

What term should be used in the nurse's documentation to describe auscultation of breath sounds that are short,popping,and discontinuous on inspiration?

A) Pleural friction rub
B) Sonorous rhonchi
C) Crackles
D) Wheeze

Question 7

In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea?

A) Review of systems
B) Chief complaint
C) Lifestyle and life patterns
D) Health history

Question 8

The nurse is obtaining vital signs on a 1-year-old child.What is the most appropriate site for assessing the pulse rate?

A) Apical
B) Radial
C) Carotid
D) Femoral

Question 9

The nurse is performing a comprehensive physical examination on a young child in the hospital.At what age can the nurse expect a child's head and chest circumferences to be almost equal?

A) Birth
B) 6 months
C) 1 year
D) 3 years

Question 10

Which assessment should the nurse perform last when examining a 5-year-old child?

A) Heart
B) Lungs
C) Abdomen
D) Throat

Question 11

Which measurement is not indicated for a 4-year-old well-child examination?

A) Blood pressure
B) Weight
C) Height
D) Head circumference

Question 12

Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child?

A) Ask the parent to quiet the child so the nurse can listen.
B) Auscultate breath sounds and chart that the child was crying.
C) Let the child play with the stethoscope for distraction.
D) Document that data are not available because of crying.

Question 13

When is the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old girl?

A) It is not necessary to inspect the genital area.
B) Examine the genital area first.
C) After the abdominal assessment
D) Do the genital inspection last.

Question 14

The nurse is admitting a toddler to the pediatric infectious disease unit.What is the single most important component of the child's physical examination?

A) Assessment of heart and lungs
B) Measurement of height and weight
C) Documentation of parental concerns
D) Obtaining an accurate history

Question 15

The nurse assesses a child's oculomotor,trochlear,and abducent nerves by using which technique?

A) Assessing the six cardinal gazes
B) Identification of common odors
C) Having child bite on a tongue blade
D) Ask child to shrug against resistance

Question 16

The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed.What does this finding indicate?

A) This is a normal finding.
B) This finding indicates premature closure of cranial sutures.
C) This is abnormal, and the child should have a developmental evaluation.
D) This is an abnormal finding, and the child should have a neurologic evaluation.

Question 17

The nurse is assessing a 4-year-old child's visual acuity.The results indicate a visual acuity of 20/40 in both eyes.The child's father asks the nurse about his son's results.Which response,if made by the nurse,is correct?

A) "Your child will need a referral to the ophthalmologist before he can attend preschool next week."
B) "Your child's visual acuity is normal for his age."
C) "The results of this test indicate your child may be color blind."
D) "Your child did not pass; he will need to see an eye doctor."

Question 18

Which strategy is not always appropriate for pediatric physical examination?

A) Take the history in a quiet, private place.
B) Examine the child from head to toe.
C) Exhibit sensitivity to cultural needs and differences.
D) Perform frightening procedures last.

Question 19

An 8-year-old girl asks the nurse how the blood pressure apparatus works.The most appropriate nursing action is to

A) ask her why she wants to know.
B) determine why she is so anxious.
C) explain in simple terms how it works.
D) tell her she will see how it works as it is used.

Question 20

The nurse percussing over an empty stomach expects to hear which sound?

A) Tympany
B) Resonance
C) Flatness
D) Dullness

Question 21

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) S₁, S₂
B) Snaps and clicks
C) Murmur
D) Physiologic splitting

Question 22

Which cranial nerve is assessed when the child is asked to imitate the examiner's wrinkled frown,wrinkled forehead,smile,and raised eyebrow?

A) Accessory
B) Hypoglossal
C) Trigeminal
D) Facial

Question 23

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

A) deep tendon reflexes.
B) cerebellar function.
C) sensory discrimination.
D) ability to follow directions.

Question 24

A nurse is performing an assessment on a newborn.Which vital signs indicate a normal finding for this age-group? (Select all that apply.)

A) Pulse of 80 to 125 a minute
B) B/P of systolic 65 to 95 and diastolic 30 to 60
C) Temperature of 36.5° to 37.3° C (axillary)
D) Temperature of 36.4° to 37° C (axillary)
E) Respirations of 30 to 60 a minute

Question 25

Which assessment finding is considered a neurologic soft sign in a 7-year-old child?

A) Plantar reflex
B) Poor muscle coordination
C) Stereognostic function
D) Graphesthesia

Question 26

Which parameter correlates best with measurements of the body's total muscle mass-to-fat ratio?

A) Height
B) Weight
C) Skinfold thickness
D) Mid-arm circumference

Question 27

A student nurse hears two registered nurses discussing a child who has neurologic soft signs.The student asks what this means.What response by the nurse is best?

A) The baby's fontanels have not yet closed.
B) Tests of neurologic function are indeterminate.
C) The child can't perform activities he should be able to.
D) The child has a significant neurologic disorder.

Question 28

A school nurse is screening children for scoliosis.Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply.)

A) Pain with deep palpation of the spinal column
B) Unequal shoulder heights
C) The trouser pant leg length appears shorter on one side
D) Inability to bend at the waist
E) Unequal waist angles

Question 29

Which tool measures body fat most accurately?

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

Question 30

Examination of the abdomen is performed correctly by the nurse in which order?

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

Question 31

What should the nurse recognize as a possible indicator of child abuse in a 4-year-old child being treated for ear pain at the emergency department on a cold winter day? (Select all that apply.)

A) The child extends his arms to be hugged by the nurse.
B) The child is wearing clean, baggy shorts, sandals, and an oversized T-shirt.
C) The child answers all questions in complete sentences and smiles afterward.
D) The child has dirty, broken teeth.
E) The child states "I'm so fat" when the nurse tells his mother he weighs 25 lb.

Question 32

Which statements about performing a pediatric physical assessment are correct for a school-age child? (Select all that apply.)

A) Physical examinations proceed systematically from head to toe.
B) The physical examination should be done with parents in the waiting room.
C) Measurement of head circumference is obtained.
D) The physical examination is done only when the child is cooperative.
E) Remove clothing and have the child put on an examination gown.

Question 33

A nurse working with infants recognizes which findings as possible signs of brain dysfunction? (Select all that apply.)

A) Irritability
B) Nausea
C) Anorexia
D) Vomiting
E) Fever

Question 34

A nurse is assessing a 12-month-old baby.What question about growth and development is most appropriate?

A) Can the baby roll over?
B) Does your baby pull himself up?
C) Is your baby cruising around yet?
D) Will your baby sit alone?

Question 35

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 36

The nurse has a 2-year-old boy sit in a "tailor" position during palpation for 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) The child does not yet have a need for privacy.

Question 37

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

A) abnormal, requiring 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.