Deck 4: Communication and Physical Assessment of the Child and Family

Question 1

What is the single most important factor to consider when communicating with children?

A) The child's physical condition
B) Presence or absence of the child's parent
C) The child's developmental level
D) The child's nonverbal behaviors

Answer 1

The child's developmental level

Question 2

What is an important consideration for the nurse who is communicating with a very young child?

A) Speak loudly, clearly, and directly.
B) Use transition objects, such as a doll.
C) Disguise own feelings, attitudes, and anxiety.
D) Initiate contact with child when parent is not present.

Answer 2

Use transition objects, such as a doll.

Question 3

Which is most likely to encourage parents to talk about their feelings related to their child's illness?

A) Be sympathetic.
B) Use direct questions.
C) Use open-ended questions.
D) Avoid periods of silence.

Answer 3

Use open-ended questions.

Question 4

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. How should this question be considered?

A) Unnecessary information because child is age 3 years
B) An important part of the family history
C) An important part of the child's past history
D) An important part of the child's review of systems

Question 5

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

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 6

The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

A) Ask her, "Are you sexually active?"
B) Ask her, "Are you having sex with anyone?"
C) Ask her, "Are you having sex with a boyfriend?"
D) Ask both the girl and her parent whether she is sexually active.

Question 7

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful?

A) Suggest that the child keep a diary.
B) Suggest that the parent read fairy tales to the child.
C) Ask the parent if the child is always uncommunicative.
D) Ask the child to draw a picture.

Question 8

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined?

A) Ask for detailed listing of symptoms.
B) Ask adolescent, "Why did you come here today?"
C) Use what adolescent says to determine, in correct medical terminology, what the problem is.
D) Interview parent away from adolescent to determine chief complaint.

Question 9

Which communication technique should the nurse avoid when interviewing children and their families?

A) Using silence
B) Using clichés
C) Directing the focus
D) Defining the problem

Question 10

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

A) Initiate a game of peek-a-boo.
B) Ask father to place the infant on the examination table.
C) Undress the infant while he is still sitting on his father's lap.
D) Talk softly to the infant while taking him from his father.

Question 11

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?

A) Indicates they live in poverty
B) Is lacking in protein
C) May provide sufficient amino acids
D) Should be enriched with meat and milk

Question 12

Which approach would be best to use to ensure a positive response from a toddler?

A) Assume an eye-level position and talk quietly.
B) Call the toddler's name while picking him or her up.
C) Call the toddler's name and say, "I'm your nurse."
D) Stand by the toddler, addressing him or her by name.

Question 13

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. How should this action be interpreted?

A) Inappropriate, because of child's age
B) A way to establish rapport
C) Too distracting, when cooperation is important
D) Acceptable, if there is adequate time

Question 14

A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern?

A) Toddler
B) Preschooler
C) School-age child
D) Adolescent

Question 15

Which is most important to document about immunizations in the child's health history?

A) Dosage of immunizations received
B) Occurrence of any reaction after an immunization
C) The exact date the immunizations were received
D) Practitioner who administered the immunizations

Question 16

When the nurse interviews an adolescent, which is especially important?

A) Focus the discussion on the peer group.
B) Allow an opportunity to express feelings.
C) Emphasize that confidentiality will always be maintained.
D) Use the same type of language as the adolescent.

Question 17

Where in the health history should the nurse describe all details related to the chief complaint?

A) Past history
B) Chief complaint
C) Present illness
D) Review of systems

Question 18

A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child?

A) Focus communication on child.
B) Explain experiences of others to child.
C) Use easy analogies when possible.
D) Assure child that communication is private.

Question 19

The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings?

A) Past history
B) Present illness
C) Chief complaint
D) Review of systems

Question 20

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?

A) Introduce self.
B) Make family comfortable.
C) Explain purpose of interview.
D) Give assurance of privacy.

Question 21

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 22

The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?

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

Question 23

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which 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 24

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 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 25

A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

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

Question 26

Which tool measures body fat most accurately?

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

Question 27

The nurse is using the Centers for Disease Control and Prevention (CDC) growth chart for an African-American child. Which statement 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 CDC growth chart is used for non-Caucasian ethnic groups.
D) The CDC charts are accurate for US African-American children.

Question 28

Which following parameters correlates best with measurements of the body's total protein stores?

A) Height
B) Weight
C) Skinfold thickness
D) Upper arm circumference

Question 29

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

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

Question 30

The nurse is using calipers to measure skinfold 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 31

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

Question 32

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 33

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. How should this action be interpreted?

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

Question 34

Which 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 35

A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child?

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.

Question 36

A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?

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

Question 37

Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age?

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

Question 38

A nurse is preparing to test a school-age child's vision. Which eye chart should the nurse use?

A) Denver Eye Screening Test
B) Allen picture card test
C) Ishihara vision test
D) Snellen letter chart

Question 39

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. How should the nurse interpret this finding?

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 40

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 41

Which of the following data would be included in a health history? (Select all that apply.)

A) Review of systems
B) Physical assessment
C) Sexual history
D) Growth measurements
E) Nutritional assessment
F) Family medical history

Question 42

A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. What is the nurse testing for?

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

Question 43

A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?

A) Up and back
B) Down and back
C) Straight back
D) Straight up

Question 44

At about what age does the Babinski sign disappear?

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

Question 45

Where is the appropriate placement of a tongue blade for assessment of the mouth and throat?

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

Question 46

A nurse is performing an assessment on a school-age child. Which findings suggest the child is getting an excess of vitamin A? (Select all that apply.)

A) Delayed sexual development
B) Edema
C) Pruritus
D) Jaundice
E) Paresthesia

Question 47

What is an appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child?

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

Question 48

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

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 49

Which 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 50

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 51

Which figure depicts a nurse performing a test for the triceps reflex?

A)
B)
C)
D)

Question 52

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)

A) Elicit one answer at a time.
B) Interrupt the interpreter if the response from the family is lengthy.
C) Comments to the interpreter about the family should be made in English.
D) Arrange for the family to speak with the same interpreter, if possible.
E) Introduce the interpreter to the family.

Question 53

A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess?

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

Question 54

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

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

Question 55

The nurse has a 2-year-old boy sit in "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 56

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 57

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

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 58

A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?

A) S3
B) S4
C) Murmur
D) Physiologic splitting

Question 59

The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?

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

Question 60

How does the nurse assess a child's capillary refill time?

A) Inspecting the chest
B) Auscultating the heart
C) Palpating the apical pulse
D) Palpating the skin to produce a slight blanching

Question 61

What is the correct sequence used when performing an abdominal assessment? Begin with the first technique and end with the last. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).

A) Auscultation
B) Palpation
C) Inspection
D) Percussion