Question 1

During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action?

Accepted Answer

The nurse is evaluating remote memory, as recalling an address involves retrieving information that has been stored for a longer period.

Question 2

A nurse caring for a school-age client notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate?

Accepted Answer

The slow disappearance of the indentation indicates edema, which could be a sign of decreased urine output and renal dysfunction. Therefore, the priority nursing assessment is to monitor the client's urine output to assess for potential renal issues.

Question 3

The nurse is assessing a school-age child's extraocular movements. The nurse recognizes which cranial nerves that involve testing extraocular movements? Select all that apply.

Accepted Answer

Cranial nerves III, IV, and VI are responsible for extraocular movements. Cranial nerve VII is responsible for facial movements and cranial nerve XII is responsible for tongue movements.

Question 4

During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be:

Accepted Answer

Asymmetric thigh and gluteal folds are a strong indicator of developmental dysplasia of the hip. This is because when the hip is dislocated, the muscle tension around the hip joint is imbalanced, leading to an asymmetrical appearance in the folds of the skin in the thigh and buttock area. Flat soles with prominent fat pads, positive Babinski reflex, and metatarsus varus are not associated with developmental dysplasia of the hip.

Question 5

The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?

Accepted Answer

Coarctation of the aorta can lead to decreased blood flow to the lower extremities and decreased blood pressure in the lower extremities. Taking blood pressures in all four extremities can help identify this defect. Tetralogy of Fallot and pulmonary atresia are typically diagnosed by echocardiogram, while a ventricular septal defect may result in a murmur but does not necessarily require blood pressure measurements in all four extremities.

Question 6

While inspecting a 5-year-old child's ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority?

Accepted Answer

The presence of a mass behind the ear and a protruding pinna could indicate an infection, such as mastoiditis. Fever is a common symptom of infection, making temperature the vital sign of priority to assess in this scenario.

Question 7

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process?

Accepted Answer

Yellowish tinted sclerae can be an indication of liver dysfunction, which is a part of the gastrointestinal system. Therefore, further evaluation of the gastrointestinal system is necessary for ongoing disease processes.

Question 8

The nurse is assessing an infant client during a health supervision visit. Which assessment findings are considered normal variations for this client? Select all that apply.

Accepted Answer

A) Sucking pads are normal finding in infants as they help them to maintain a sucking motion for feeding.

B) Infants usually have a rounded chest until about two years old when it takes on a more adult shape.

C) Hearing breath sounds over the entire chest is normal as infants typically have narrow airways and lack the anatomical structures that can restrict air movement.

D) Pubertal development is not typical in infants and would be concerning if present.

E) Knock-knees can be a normal developmental variation in toddlers but typically resolve by around age 7.

Question 9

The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first?

Accepted Answer

Stridor is a serious, potentially life-threatening symptom that requires immediate evaluation and intervention. The other options are important to assess, but they do not require immediate attention like stridor does.

Question 10

When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old?

Accepted Answer

Repeating an address tests remote memory, as it involves recalling information learned over time.

Question 11

A new mother is worried about a "soft spot" on the top of her newborn infant's head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close?

Accepted Answer

The anterior fontanel typically closes between 12 to 18 months of age.

Question 12

The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family?

Accepted Answer

Option C is an open-ended statement that invites the family to share their concerns, which establishes rapport and helps the nurse to understand their needs. This statement shows empathy and respect for the family, making them more likely to share information freely. Option A is too direct and may make the family feel uncomfortable or defensive. Option B is polite but does not elicit any information. Option D is too directive and may make the family feel overwhelmed or rushed.

Question 13

The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth.

Accepted Answer

The tape measure should be placed just above the umbilicus, around the largest circumference of the abdomen, for an accurate measurement of abdominal girth. This area typically corresponds to the widest area of the abdominal distension. Placing the tape measure below the umbilicus, just below the sternum, or just above the pubic bone would not provide an accurate measurement of abdominal girth.

Question 14

A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? Select all that apply.

Accepted Answer

The answer of A 7-year-old child presents to the clinic...

Question 15

The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infant's growth pattern since birth? Select all that apply.

Accepted Answer

Weight, height, and head circumference are all appropriate methods to monitor an infant's growth pattern since birth. Body mass index (BMI) is not typically used to monitor growth in infants under 2 years of age.

Question 16

The nurse is preparing to assess a toddler client. Which activities would gain cooperation from the toddler? Select all that apply.

Accepted Answer

The answer of The nurse is preparing to assess a...

Question 17

Place the nursing assessments of a toddler in the best order.
A) Examination of eyes, ears, and throat
B) Auscultation of chest
C) Palpation of abdomen
D) Developmental assessment

Accepted Answer

The answer of Place the nursing assessments of a toddler...

Question 18

The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to:

Accepted Answer

A grade III heart murmur is characterized by a moderately loud murmur that is easily heard but does not have a palpable thrill.

Quiz 5: Pediatric Assessment