Deck 34: Communication, history, physical and Developmental Assessment

Question 1

What action 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 1

Use open-ended questions.

Question 2

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

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

Answer 2

The child's developmental level

Question 3

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 3

Use transition objects such as a doll.

Question 4

Which tool measures body fat most accurately?

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

Question 5

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 6

The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that:

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 NCHS growth chart is used for non-Caucasian ethnic groups.
D)The NCHS charts are accurate for U.S. African-American children.

Question 7

An appropriate approach to performing a physical assessment on a toddler is to:

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 8

When introducing hospital equipment to a preschooler who seems afraid,the nurse's approach should be based on which principle?

A)The child may think the equipment is alive.
B)The child is too young to understand what the equipment does.
C)Explaining the equipment will only increase the child's fear.
D)One brief explanation is enough to reduce the child's fear.

Question 9

Which age group is most concerned with body integrity?

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

Question 10

With the National Center for Health Statistics (NCHS) criteria,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 11

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

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 if she is sexually active.

Question 12

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

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

Question 13

When the nurse interviews an adolescent,it is especially important to:

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 14

The nurse is taking a health history on an adolescent. What 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 15

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are:

A)Unnecessary information because the child is age 3 years.
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.

Question 16

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 the family comfortable.
C)Explain the purpose of the interview.
D)Give an assurance of privacy.

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

When doing a nutritional assessment on an Hispanic family,the nurse learns that their diet consists mainly of vegetables,legumes,and starches. The nurse should recognize that this diet:

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

Question 19

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

A)Height
B)Weight
C)Skin-fold thickness
D)Upper arm circumference

Question 20

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 21

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 22

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

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

Question 23

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

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 24

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)Physiologic splitting

Question 25

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 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 26

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

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

Question 27

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

A)2 months
B)2 to 4 months
C)6 to 8 months
D)12 to 18 months

Question 28

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

A)1 year
B)2 years
C)3 years
D)6 years

Question 29

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

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

Question 30

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 31

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

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

Question 32

Examination of the abdomen is performed correctly by the nurse in this order:

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

Question 33

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:

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 34

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

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 35

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 36

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

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

Question 37

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:

A)A normal finding.
B)An abnormal finding;child needs referral to ophthalmologist.
C)A sign of possible visual defect;child needs vision screening.
D)A sign of small hemorrhages,which usually resolve spontaneously.

Question 38

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 in determining the appropriate-size blood pressure cuff? Choose 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 39

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

A)1 month
B)6 to 9 months
C)1 to 2 years
D)2.5 to 3 years

Question 40

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 41

Which data would be included in a health history? Choose all that apply.

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