Question 1

A nurse is taking the sexual history of an adolescent girl.Which is the best way to determine whether she is sexually active?&#10;A) Ask, &#34;Are you sexually active?&#34;&#10;B) Ask, &#34;Are you having sex with anyone?&#34;&#10;C) Ask, &#34;Are you having sex with a boyfriend?&#34;&#10;D) Ask both the girl and her parent if she is sexually active.

Accepted Answer

Asking the adolescent girl if she is having sex with anyone is a direct question that is easy to understand.The phrase sexually active is broadly defined and may not give specific enough information for the nurse to provide the necessary care.The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend,because homosexual experimentation may occur.Questioning about sexual activity should occur when the adolescent is alone.

Question 2

What approach is most likely to encourage parents to talk about their feelings related to their child's illness?&#10;A) Being sympathetic&#10;B) Using direct questions&#10;C) Using open-ended questions&#10;D) Avoiding periods of silence

Accepted Answer

Closed-ended questions should be avoided when attempting to elicit parents' feelings.Open-ended questions require the parent to respond with more than a brief Answerwer.Sympathy is defined as having feelings or emotions in common with another person,rather than understanding those feelings (which is called empathy).Sympathy is not therapeutic in the helping relationship.Direct questions may only obtain limited information.In addition,the parent may consider them threatening.Silence can be an effective interviewing tool.It allows two or more people to share feelings and absorb one another's emotions in depth.Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.

Question 3

According to the WHO Growth Reference Charts,which body mass index (BMI)-for-age percentile indicates a risk for being overweight?&#10;A) 10th percentile&#10;B) 25th percentile&#10;C) 90th percentile&#10;D) 95th percentile

Accepted Answer

The 2007 WHO Growth Reference Charts include data that reflect healthy growth and can be used to identify children who are at risk for obesity.Children who have BMI-for-age greater than or equal to the 90th percentile are at risk.Children in the 10th and 25th percentiles are within normal limits.Children who are greater than or equal to the 95th percentile are considered overweight.

Question 4

A nurse knows that the patient is experiencing information overload when she observes that the patient is doing one of the following?&#10;A) Maintains eye contact&#10;B) Plays with hair&#10;C) Has fixed, narrowed eyes&#10;D) Remains focused on the topic of discussion

Accepted Answer

Nervous habits,such as playing with one's hair,are a sign that the patient has information overload.Other signs include avoiding eye contact,wide eyes,and attempting to change the topic of discussion.

Question 5

Which of the following statements describes the emerging illocutionary stage?&#10;A) The child is reflexive to stimuli.&#10;B) The child shows increasing purpose in action.&#10;C) The child communicates intentionally with signals and gestures.&#10;D) The child communicates intentionally with vocalizations and verbalizations.

Accepted Answer

The emerging illocutionary stage (8-9 to 12-15 months)is when the child communicates intentionally with signals and gestures.The child reflexive to stimuli and showing increasing purpose in action is in the perlocutionary stage.The child communicating intentionally with vocalizations and verbalizations is in the conventional illocutionary-emerging locutionary stage.

Question 6

The nurse is seeing an adolescent boy and his parents in the clinic for the first time.What should the nurse do first?&#10;A) Introduce him- or herself.&#10;B) Make the family comfortable.&#10;C) Explain the purpose of the interview.&#10;D) Give an assurance of privacy.

Accepted Answer

The first thing that nurses must do is introduce themselves to the patient and family.Parents and other adults should be addressed with appropriate titles unless they specify a preferred name.During the initial part of the interview,the nurse should include general conversation to help make the family feel at ease.Next,the purpose of the interview and the nurse's role should be clarified.The interview should take place in an environment as free of distraction as possible.In addition,the nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality.

Question 7

What is the most important thing for a nurse to say when interviewing an adolescent?&#10;A) Focus the discussion on the peer group.&#10;B) Allow for an opportunity to express feelings.&#10;C) Emphasize that confidentiality will always be maintained.&#10;D) Use the same type of language as the adolescent.

Accepted Answer

Adolescents,like all children,need an opportunity to express their feelings.Often they will inject feelings into their words.The nurse must be alert to both the words and feelings expressed.Although their peer group is important to those in this age group,the focus of the interview should be on the individual adolescent.The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality.The nurse should maintain a professional relationship with the adolescent.To avoid misinterpretation of words and phrases that the adolescent may use,the nurse should clarify terms frequently.

Question 8

What is the single most important factor to consider when communicating with children?&#10;A) The child's physical condition&#10;B) The presence or absence of the child's parent&#10;C) The child's developmental level&#10;D) The child's non-verbal behaviours

Accepted Answer

The nurse must be aware of the child's developmental stage to engage in effective communication.An understanding of the typical characteristics of these stages provides the nurse with a framework to facilitate social communication.The use of both verbal and non-verbal communication should be appropriate to the developmental level.Although the child's physical condition is a consideration,developmental level is much more important.The parents' presence is important when communicating with young children,but it may be detrimental when speaking with adolescents.Non-verbal behaviours vary in importance based on the child's developmental level.

Question 9

Which one of the following is an appropriate approach to performing a physical assessment on a toddler?&#10;A) Always proceed in a head-to-toe direction.&#10;B) Perform traumatic procedures first.&#10;C) Use minimum physical contact initially.&#10;D) Demonstrate use of equipment.

Accepted Answer

Parents can remove clothing,and the child can remain on the parent's lap.The nurse should use minimum physical contact initially to gain the child's cooperation.The head-to-toe assessment can be done in older children,but usually must be adapted for younger children.Traumatic procedures should always be performed last because they will most likely upset the child and inhibit cooperation.The nurse should introduce the equipment slowly.The child can inspect the equipment,but demonstrations are usually too complex for this age group.

Question 10

Which age group is most concerned with body integrity?&#10;A) Toddlers&#10;B) Preschoolers&#10;C) School-age children&#10;D) Adolescents

Accepted Answer

School-age children have heightened concerns about body integrity.They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggests injury.Body integrity is not as important to children in the toddler,preschooler,and adolescent age groups.

Question 11

When introducing hospital equipment to a preschooler who seems afraid,which of the following principles should the nurse keep in mind?&#10;A) The child may think the equipment is alive.&#10;B) The child is too young to understand what the equipment does.&#10;C) Explaining the equipment will only increase the child's fear.&#10;D) One brief explanation is enough to reduce the child's fear.

Accepted Answer

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Question 12

A nurse is taking the health history of an adolescent.Which statement best describes how to determine the chief complaint?&#10;A) Ask for a detailed listing of symptoms.&#10;B) Ask the adolescent, &#34;Why did you come here today?&#34;&#10;C) Use what adolescent says to determine, in correct medical terminology, what the problem is.&#10;D) Interview the parent away from adolescent to determine chief complaint.

Accepted Answer

The answer of A nurse is taking the health history...

Question 13

Which tool measures body fat most accurately?&#10;A) Stadiometer&#10;B) Calipers&#10;C) Cloth tape measure&#10;D) Paper or metal tape measure

Accepted Answer

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Question 14

An 8-year-old girl asks the nurse how the blood pressure apparatus works.What is the most appropriate act for the nurse to take?&#10;A) Ask her why she wants to know.&#10;B) Determine why she is so anxious.&#10;C) Explain in simple terms how it works.&#10;D) Tell her she will see how it works when it is used.

Accepted Answer

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Question 15

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones,such as the age when he started walking without assistance.How should milestones be considered?&#10;A) They are unnecessary because the child is age 3 years.&#10;B) They are an important part of the family history.&#10;C) They are an important part of the child's past growth and development.&#10;D) They are an important part of the child's review of systems.

Accepted Answer

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Question 16

Which parameter correlates best with measurements of the body's total protein stores?&#10;A) Height&#10;B) Weight&#10;C) Skin-fold thickness&#10;D) Upper arm circumference

Accepted Answer

The answer of Which parameter correlates best with measurements of...

Question 17

What is an important consideration for the nurse who is communicating with a very young child?&#10;A) Speak loudly, clearly, and directly.&#10;B) Use transition objects, such as a doll.&#10;C) Disguise one's own feelings, attitudes, and anxiety.&#10;D) Initiate contact with the child when his or her parent is not present.

Accepted Answer

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Question 18

Where in the health history should the nurse describe all the details related to the chief complaint?&#10;A) Past history&#10;B) Chief complaint&#10;C) Present illness&#10;D) Review of systems

Accepted Answer

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Question 19

The nurse is interviewing the mother of an infant.She reports,&#34;I had a difficult delivery,and my baby was born prematurely.&#34; This information should be recorded under which heading?&#10;A) Birth history&#10;B) Present illness&#10;C) Chief complaint&#10;D) Review of systems

Accepted Answer

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Question 20

The nurse is having difficulty communicating with a hospitalized 6-year-old child.What technique is most helpful in improving communication?&#10;A) Suggest that the child keep a diary.&#10;B) Suggest that the parent read fairytales to the child.&#10;C) Ask the parent if the child is always uncommunicative.&#10;D) Ask the child to draw a picture.

Accepted Answer

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Question 21

Kimberly is having a checkup before starting kindergarten.The nurse asks her to do the &#34;finger-to-nose&#34; test.What is the nurse testing for?&#10;A) Deep tendon reflexes&#10;B) Cerebellar function&#10;C) Sensory discrimination&#10;D) Ability to follow directions

Accepted Answer

The answer of Kimberly is having a checkup before starting...

Question 22

During an examination of a toddler's extremities,the nurse notes that the child is bowlegged.How should the nurse document this finding?&#10;A) It is abnormal and requires further investigation.&#10;B) It is abnormal unless it occurs in conjunction with knock-knee.&#10;C) It is normal if the condition is unilateral or asymmetric.&#10;D) It is normal because the lower back and leg muscles are not yet well developed.

Accepted Answer

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Question 23

What is the earliest age at which a satisfactory radial pulse can be taken in children?&#10;A) 1 year&#10;B) 2 years&#10;C) 3 years&#10;D) 6 years

Accepted Answer

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Question 24

What is the correct order of the steps for examining the abdomen?&#10;A) Inspection, palpation, and auscultation&#10;B) Palpation, inspection, and auscultation&#10;C) Palpation, auscultation, and inspection&#10;D) Inspection, auscultation, and palpation

Accepted Answer

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Question 25

What is the appropriate placement for a tongue blade to assess the mouth and throat?&#10;A) Centre back area of tongue&#10;B) Side of the tongue&#10;C) Against the soft palate&#10;D) On the lower jaw

Accepted Answer

The answer of What is the appropriate placement for a...

Question 26

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?&#10;A) Face&#10;B) Buttocks&#10;C) Oral mucosa&#10;D) Palms and soles

Accepted Answer

The answer of Where is the best place to observe...

Question 27

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup.Which criteria should the nurse use to determine the appropriate-size blood pressure cuff?&#10;A) The cuff is labelled &#34;toddler.&#34;&#10;B) The cuff bladder width is approximately 80% of the circumference of the upper arm.&#10;C) The cuff bladder length covers 80% to 100% of the circumference of the upper arm.&#10;D) The cuff bladder covers 50% to 66% of the length of the upper arm.

Accepted Answer

The answer of The nurse must check vital signs on...

Question 28

By what age do the head and chest circumferences generally become equal?&#10;A) 1 month&#10;B) 6 to 9 months&#10;C) 1 to 2 years&#10;D) 2.5 to 3 years

Accepted Answer

The answer of By what age do the head and...

Question 29

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.What is the priority action?&#10;A) Refer for immediate medical evaluation.&#10;B) Continue assessment to determine cause of neck pain.&#10;C) Ask parent when neck was injured.&#10;D) Record &#34;head lag&#34; on assessment record and continue assessment of child.

Accepted Answer

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Question 30

The nurse is testing an infant's visual acuity.By what age should the infant be able to fix on and follow a target?&#10;A) 1 month&#10;B) 1 to 2 months&#10;C) 3 to 4 months&#10;D) 6 months

Accepted Answer

The answer of The nurse is testing an infant's visual...

Question 31

Binocularity,the ability to fixate on one visual field with both eyes simultaneously,is normally present by what age?&#10;A) 1 month&#10;B) 3 to 4 months&#10;C) 6 to 8 months&#10;D) 12 months

Accepted Answer

The answer of Binocularity,the ability to fixate on one visual...

Question 32

During a funduscopic examination of a school-aged child,the nurse notes a brilliant,uniform red reflex in both eyes.The nurse should recognize that this is which of the following?&#10;A) A normal finding&#10;B) An abnormal finding; the child needs a referral to an ophthalmologist&#10;C) A sign of possible visual defect; the child needs vision screening&#10;D) A sign of small hemorrhages, which usually resolve spontaneously

Accepted Answer

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Question 33

The nurse has a 2-year-old boy sit in the &#34;tailor&#34; position during palpation for the testes.What is the rationale for this position?&#10;A) It prevents cremasteric reflex.&#10;B) Undescended testes can be palpated.&#10;C) This tests the child for an inguinal hernia.&#10;D) The child does not yet have a need for privacy.

Accepted Answer

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Question 34

What is the most frequently used test for measuring visual acuity?&#10;A) Denver Eye Screening test&#10;B) Allen picture card test&#10;C) Ishihara vision test&#10;D) Snellen letter chart

Accepted Answer

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Question 35

How should the nurse assess a child's capillary filling time?&#10;A) Inspect the chest.&#10;B) Auscultate the heart.&#10;C) Palpate the apical pulse.&#10;D) Palpate the skin to produce a slight blanching.

Accepted Answer

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Question 36

When palpating a child's cervical lymph nodes,the nurse notes that they are tender,enlarged,and warm.What is the best explanation for this finding?&#10;A) Some form of cancer&#10;B) Local scalp infection common in children&#10;C) Infection or inflammation distal to the site&#10;D) Infection or inflammation close to the site

Accepted Answer

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Question 37

When teaching new parents about their infants' anterior fontanel,the nurse tells them that it will close at which age?&#10;A) 2 months&#10;B) 2 to 4 months&#10;C) 6 to 8 months&#10;D) 12 to 18 months

Accepted Answer

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Question 38

Which term is used to describe breath sounds that are produced as air passes through narrowed passageways?&#10;A) Rubs&#10;B) Rattles&#10;C) Wheezes&#10;D) Crackles

Accepted Answer

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Question 39

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) S₃, S₄ C) Murmur D) Physiological splitting

Accepted Answer

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Question 40

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?&#10;A) Vesicular&#10;B) Bronchial&#10;C) Adventitious&#10;D) Bronchovesicular

Accepted Answer

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Question 41

Which data is included in a health history?&#10;A) Review of systems&#10;B) Physical assessment&#10;C) Vital sign assessment&#10;D) Growth measurements

Accepted Answer

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Deck 34: Communication, history, physical, and Developmental Assessment