Question 1

The nurse is administering the Denver II to a 16-week-old infant who was born 4 weeks early. At what age should the infant be tested?

Accepted Answer

When administering the Denver II to an infant born prematurely, the infant's age should be adjusted for prematurity. In this case, since the infant was born 4 weeks early, you subtract 4 weeks from the infant's chronological age (16 weeks) to get the adjusted age for testing, which is 12 weeks.

Question 2

An appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child is which of the following?

Accepted Answer

Conventional audiometry is appropriate for a 5-year-old child because at this age, children can typically follow instructions and respond to the sounds they hear during the test, making it a suitable method for screening hearing. The Rinne and Weber tests are more suitable for older children and adults who can reliably report their perceptions of sound, and eliciting the startle reflex is not a specific test for hearing in this age group.

Question 3

The nurse has determined the rate of both the child's radial pulse and heart. When comparing the two rates, the nurse should expect that normally they:

Accepted Answer

Normally, the rate of a child's radial pulse and heart rate should be the same, as the radial pulse is a peripheral reflection of the heart's activity.

Question 4

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

Accepted Answer

The "finger-to-nose" test is a common neurological examination used to assess cerebellar function. This test checks for coordination and fine motor control, which are governed by the cerebellum.

Question 5

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

Accepted Answer

Cheyne-Stokes respirations are characterized by a gradual increase in the depth of respirations, followed by a gradual decrease and then a period of apnea, which matches the description given.

Question 6

When auscultating an infant's lungs, the nurse detects diminished breath sounds. The nurse should interpret this as which of the following?

Accepted Answer

Diminished breath sounds in an infant are not normal and could indicate a problem with air movement in the lungs, such as blockage or fluid in the airways. This finding warrants further investigation to determine the cause.

Question 7

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

Accepted Answer

Bowleggedness (genu varum) is a common condition in toddlers and is considered normal due to the fact that their lower back and leg muscles are not yet fully developed. This condition typically corrects itself as the child grows and strengthens these muscles.

Question 8

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

Accepted Answer

Wheezes are breath sounds that are produced as air passes through narrowed passageways, often due to asthma, COPD, or bronchitis.

Question 9

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

Accepted Answer

The correct sequence for abdominal examination is inspection, auscultation, and then palpation. This order is important because palpation can stimulate bowel movements, potentially altering the sounds you would auscultate if it were done before auscultation.

Question 10

Which of the following is the most appropriate vision acuity test for a child who is in preschool?

Accepted Answer

The HOTV chart is specifically designed for young children, including those in preschool, who may not yet know their letters. It uses simple shapes and a matching game approach, making it easier for young children to participate in the vision screening.

Question 11

The nurse is beginning to administer the Denver II to a small child when his mother says, "Can you tell me again what this Denver II is?" The nurse's best response is which of the following?

Accepted Answer

The answer of The nurse is beginning to administer the...

Question 12

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?

Accepted Answer

By 3 to 4 months of age, an infant should be able to fix on and follow a target.

Question 13

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?

Accepted Answer

Vesicular breath sounds are the normal sounds heard over most of the lung surface. They are soft, low-pitched, and are heard throughout inspiration and continue without pause through expiration.

Question 14

The nurse has a 2-year-old boy sit in "tailor" position while palpating for the presence of the testes. What is the rationale for this position?

Accepted Answer

The "tailor" position, which involves sitting with crossed legs, helps prevent the cremasteric reflex. This reflex can cause the testes to retract into the inguinal canal, making them difficult to palpate. By preventing this reflex, the nurse can more accurately assess the presence and position of the testes.

Question 15

At about what age does the Babinski sign disappear?

Accepted Answer

The answer of At about what age does the Babinski...

Question 16

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Accepted Answer

Murmurs are produced by turbulent blood flow within the heart chambers or in the major arteries, which causes vibrations that can be heard as a heart sound.

Question 17

What is the most frequently used test for measuring visual acuity?

Accepted Answer

The Snellen Letter Chart is the most frequently used test for measuring visual acuity. It consists of rows of letters decreasing in size, which the patient reads from a specific distance.

Question 18

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

Accepted Answer

The appropriate-size blood pressure cuff for a child should have a bladder width that is approximately 40% of the circumference of the upper arm and a bladder length that covers 80% to 100% of the circumference of the upper arm. These criteria ensure that the cuff fits properly and provides accurate blood pressure readings.

Question 19

The appropriate placement of a tongue blade for assessment of the mouth and throat is which of the following?

Accepted Answer

Placing the tongue blade on the side of the tongue allows for better visualization of the throat without triggering the gag reflex.

Question 20

The nurse must assess a child's capillary filling time. This can be accomplished by doing which of the following?

Accepted Answer

Capillary refill time is assessed by applying pressure to the skin to cause blanching, then observing how long it takes for the color to return once pressure is released. This is a measure of peripheral perfusion and can indicate circulatory efficiency.

Quiz 7: Physical and Developmental Assessment of the Child