Question 1

The nurse has just started assessing a young child who is febrile and appears ill.There is hyperextension of the child's head (opisthotonos)with pain on flexion.Which is the most appropriate action?
A) Ask the parent when the neck was injured.
B) Refer for immediate medical evaluation.
C) Continue assessment to determine the cause of the neck pain.
D) Record "head lag" on the assessment record and continue the assessment of the child.

Accepted Answer

Hyperextension of the child's head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation.No indication of injury is present.This situation is not descriptive of head lag.

Question 2

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 which?
A) A normal finding
B) A sign of a possible visual defect and a need for vision screening
C) An abnormal finding requiring referral to an ophthalmologist
D) A sign of small hemorrhages, which usually resolve spontaneously

Accepted Answer

A brilliant,uniform red reflex is an important normal finding.It rules out many serious defects of the cornea,aqueous chamber,lens,and vitreous chamber.

Question 3

When auscultating an infant's lungs,the nurse detects diminished breath sounds.What should the nurse interpret this as?
A) Suggestive of chronic pulmonary disease
B) Suggestive of impending respiratory failure
C) An abnormal finding warranting investigation
D) A normal finding in infants younger than 1 year of age

Accepted Answer

Absent or diminished breath sounds are always an abnormal finding.Fluid,air,or solid masses in the pleural space all interfere with the conduction of breath sounds.Further data are necessary for diagnosis of chronic pulmonary disease or impending respiratory failure.Diminished breath sounds in certain segments of the lungs can alert the nurse to pulmonary areas that may benefit from chest physiotherapy.Further evaluation is needed in all age groups.

Question 4

During an otoscopic examination on an infant,in which direction is the pinna pulled?
A) Up and back
B) Up and forward
C) Down and back
D) Down and forward

Accepted Answer

In infants and toddlers,the ear canal is curved upward.To visualize the ear canal,it is necessary to pull the pinna down and back to the 6 to 9 o'clock range to straighten the canal.In children older than age 3 years and adults,the canal curves downward and forward.The pinna is pulled up and back to the 10 o'clock position.Up and forward and down and forward are positions that do not facilitate visualization of the ear canal.

Question 5

Examination of the abdomen is performed correctly by the nurse in which order?
A) Inspection, palpation, percussion, and auscultation
B) Inspection, percussion, auscultation, and palpation
C) Palpation, percussion, auscultation, and inspection
D) Inspection, auscultation, percussion, and palpation

Accepted Answer

The correct order of abdominal examination is inspection,auscultation,percussion,and palpation.Palpation is always performed last because it may distort the normal abdominal sounds.Auscultation is performed before percussion.The act of percussion can influence the findings on auscultation.

Question 6

Which explains the importance of detecting strabismus in young children?
A) Color vision deficit may result.
B) Amblyopia, a type of blindness, may result.
C) Epicanthal folds may develop in the affected eye.
D) Corneal light reflexes may fall symmetrically within each pupil.

Accepted Answer

By the age of 3 to 4 months,infants are able to fixate on one visual field with both eyes simultaneously.In strabismus,or cross-eye,one eye deviates from the point of fixation.If misalignment is constant,the weak eye becomes "lazy," and the brain eventually suppresses the image produced from that eye.If strabismus is not detected and corrected by age 4 to 6 years,blindness from disuse,known as amblyopia,may occur.Color vision is not the only concern.Epicanthal folds are not related to amblyopia.In children with strabismus,the corneal light reflex will not be symmetric for each eye.

Question 7

When assessing a preschooler's chest,what should the nurse expect?
A) Respiratory movements to be chiefly thoracic
B) Anteroposterior diameter to be equal to the transverse diameter
C) Retraction of the muscles between the ribs on respiratory movement
D) Movement of the chest wall to be symmetric bilaterally and coordinated with breathing

Accepted Answer

Movement of the chest wall should be symmetric bilaterally and coordinated with breathing.In children younger than 6 or 7 years,respiratory movement is principally abdominal or diaphragmatic.The anteroposterior diameter is equal to the transverse diameter during infancy.As the child grows,the chest increases in the transverse direction,so that the anteroposterior diameter is less than the lateral diameter.Retractions of the muscles between the ribs on respiratory movement are indicative of respiratory distress.

Question 8

Which is the most frequently used test for measuring visual acuity?
A) Snellen letter chart
B) Ishihara vision test
C) Allen picture card test
D) Denver eye screening test

Accepted Answer

The Snellen letter chart,which consists of lines of letters of decreasing size,is the most frequently used test for visual acuity.The Ishihara Vision Test is used for color vision.The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snellen letter chart.

Question 9

During a routine health assessment,the nurse notes that an 8-month-old infant has a significant head lag.Which is the most appropriate action?
A) Recheck head control at next visit.
B) Teach the parents appropriate exercises.
C) Schedule the child for further evaluation.
D) Refer the child for further evaluation if the anterior fontanel is still open.

Accepted Answer

Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation.Head control is part of normal development.Exercises will not be effective.The lack of achievement of this developmental milestone must be evaluated.

Question 10

The nurse needs to take the blood pressure of a small child.Of the cuffs available,one is too large and one is too small.The best nursing action is which?
A) Use the small cuff.
B) Use the large cuff.
C) Use either cuff using the palpation method.
D) Wait to take the blood pressure until a proper cuff can be located.

Accepted Answer

If blood pressure measurement is indicated and the appropriate size cuff is not available,the next larger size is used.The nurse recognizes that this may be a falsely low blood pressure.Using the small cuff will give an incorrectly high reading.The palpation method will not improve the inaccuracy inherent in the cuff.

Question 11

Which 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

Accepted Answer

This is the definition of vesicular breath sounds.They are heard over the entire surface of the lungs,with the exception of the upper intrascapular area and the area beneath the manubrium.Bronchial breath sounds are heard only over the trachea near the suprasternal notch.Adventitious breath sounds are not usually heard over the chest.These sounds occur in addition to normal or abnormal breath sounds.Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions,where the trachea and bronchi bifurcate.

Question 12

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

Accepted Answer

Petechiae,small distinct pinpoint hemorrhages,are difficult to see in dark-skinned individuals unless they are in the mouth or conjunctiva.

Question 13

The nurse is assessing a child's capillary refill time.This can be accomplished by doing what?
A) Inspect the chest.
B) Auscultate the heart.
C) Palpate the apical pulse.
D) Palpate the nail bed with pressure to produce a slight blanching.

Accepted Answer

Capillary refill time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill.Inspecting the chest,auscultating the heart,and palpating the apical pulse will not provide an assessment of capillary refill time.

Question 14

The nurse is caring for a non-English-speaking child and family.Which should the nurse consider when using an interpreter?
A) Pose several questions at a time.
B) Use medical jargon when possible.
C) Communicate directly with family members when asking questions.
D) Carry on some communication in English with the interpreter about the family's needs.

Accepted Answer

When using an interpreter,the nurse should communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions.Questions should be posed one at a time to elicit only one answer at a time.Medical jargon should be avoided whenever possible.The nurse should avoid discussing the family's needs with the interpreter in English because some family members may understand some English.

Question 15

Superficial palpation of the abdomen is often perceived by the child as tickling.Which measure by the nurse is most likely to minimize this sensation and promote relaxation?
A) Palpate another area simultaneously.
B) Ask the child not to laugh or move if it tickles.
C) Begin with deeper palpation and gradually progress to superficial palpation.
D) Have the child "help" with palpation by placing his or her hand over the palpating hand.

Accepted Answer

Having the child "help" with palpation by placing his or her hand over the palpating hand will help minimize the feeling of tickling and enlist the child's cooperation.Palpating another area simultaneously will create the sensation of tickling in the other area also.Asking the child not to laugh or move will bring attention to the tickling and make it more difficult for the child.Superficial palpation is done before deep palpation.

Question 16

What is the appropriate placement of a tongue blade for assessment of the mouth and throat?
A) On the lower jaw
B) Side of the tongue
C) Against the soft palate
D) Center back area of the tongue

Accepted Answer

The side of the tongue is the correct position.It avoids the gag reflex yet allows visualization.On the lower jaw and against the soft palate are not appropriate places for the tongue blade.Placement in the center back area of the tongue elicits the gag reflex.

Question 17

Which 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 and S2
B) S3 and S4
C) Murmur
D) Physiologic splitting

Accepted Answer

Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood.S1 and S2 are normal heart sounds.S1 is the closure of the tricuspid and mitral valves,and S2 is the closure of the pulmonic and aortic valves.S3 is a normal heart sound sometimes heard in children.S4 is rarely heard as a normal heart sound.If it is heard,medical evaluation is required.Physiologic splitting is the distinction of the two sounds in S2,which widens on inspiration.It is a significant normal finding.

Question 18

The nurse is testing an infant's visual acuity.By which 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

Accepted Answer

Visual fixation and ability to follow a target should be present by ages 3 to 4 months.One to 2 months is too young for this developmental milestone.If an infant is not able to fix and follow by 6 months,further ophthalmologic evaluation is needed.

Question 19

What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
A) Rinne test
B) Weber test
C) Pure tone audiometry
D) Eliciting the startle reflex

Accepted Answer

Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the child's ears.The child is asked to respond in some way when the tone is heard in the earphone.The Rinne and Weber tests measure bone conduction of sound.Eliciting the startle reflex may be useful in infants.

Question 20

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

Accepted Answer

Lateral bowing of the tibia (bowlegged)is an expected finding in toddlers when they begin to walk.It usually persists until all of their lower back and leg muscles are well developed.Further evaluation is needed if it persists beyond ages 2 to 3 years,especially in African American children.

Quiz 4: Communication, physical, and Developmental Assessment

The nurse has just started assessing a young child who is febrile and appears ill.There is hyperextension of the child's head (opisthotonos) with pain on flexion.Which is the most appropriate action?

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 which?

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

During an otoscopic examination on an infant,in which direction is the pinna pulled?

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

Which explains the importance of detecting strabismus in young children?

When assessing a preschooler's chest,what should the nurse expect?

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

During a routine health assessment,the nurse notes that an 8-month-old infant has a significant head lag.Which is the most appropriate action?

The nurse needs to take the blood pressure of a small child.Of the cuffs available,one is too large and one is too small.The best nursing action is which?

Which 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?

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

The nurse is assessing a child's capillary refill time.This can be accomplished by doing what?

The nurse is caring for a non-English-speaking child and family.Which should the nurse consider when using an interpreter?

Superficial palpation of the abdomen is often perceived by the child as tickling.Which measure by the nurse is most likely to minimize this sensation and promote relaxation?

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

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

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

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

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