Deck 5: Pediatric Assessment

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?
1) Recent memory
2) Language development
3) Remote memory
4) Social-skill development

Answer 1

3

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?
1) Skin integrity, especially in the lower extremities
2) Urine output
3) Level of consciousness
4) Range of motion and ankle mobility

Answer 2

2

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.
1) VII
2) III
3) IV
4) XII
5) VI

Answer 3

2, 3, 5

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:
1) soles are flat with prominent fat pads.
2) positive Babinski reflex.
3) metatarsus varus.
4) asymmetric thigh and gluteal folds.

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?
1) Tetralogy of Fallot
2) Pulmonary atresia
3) Coarctation of the aorta
4) Ventricular septal defect

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?
1) Temperature
2) Heart rate
3) Respirations
4) Blood pressure

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?
1) Cardiac
2) Respiratory
3) Gastrointestinal
4) Genitourinary

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.
1) Sucking pads in the mouth
2) A rounded chest
3) Hearing breath sounds over the entire chest
4) Pubertal development
5) Knock-knees

Question 9

The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first?
1) A child with a temperature of 101 degrees F
2) A child who has stridor
3) A child who has absent Babinski sign
4) A child who has a pot belly appearance

Question 10

When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old?
1) Say the name of an object and after 5 minutes ask the child to tell you what you said the object was.
2) Ask the child to repeat his address.
3) Ask the child to say a poem and listen to the child's speech articulation.
4) Have the child point to various parts of the body as you name them.

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?
1) 2 to 3 months of age
2) 6 to 9 months of age
3) 12 to 18 months of age
4) Approximately 2 years 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?
1) "Does any member of your family have a history of asthma, heart disease, or diabetes?"
2) "Hello, I would like to talk with you and get some information on you and your child."
3) "Tell me about the concerns that brought you to the clinic today."
4) "You will need to fill out these forms; make sure that the information is as complete as possible."

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.
1) Just above the umbilicus, around the largest circumference of the abdomen
2) Below the umbilicus
3) Just below the sternum
4) Just above the pubic bone

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.
1) Wheezing
2) Increased tactile fremitus
3) Decreased vocal resonance
4) Decreased tactile fremitus
5) Bronchophony

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.
1) Weight the infant twice and average together
2) Measure the infant's height
3) Measure the infant's head circumference
4) Determine the infant's body mass index
5) Plot the infant's growth on appropriate chart

Question 16

The nurse is preparing to assess a toddler client. Which activities would gain cooperation from the toddler? Select all that apply.
1) Asking the parents to wait outside
2) Allowing the client to sit in the parent's lap
3) Administering vaccinations prior to the assessment
4) Handing the client a stethoscope while taking the health history
5) Making a game out of the assessment process

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

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:
1) Auscultate a quiet but easily heard murmur.
2) Auscultate a moderately loud murmur without a palpable thrill.
3) Auscultate a very loud murmur with easily palpable thrill.
4) Listen without a stethoscope and hear a murmur at chest wall.