Deck 4: Communication, Physical, and Developmental Assessment

Question 1

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

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

Answer 1

The child may think the equipment is alive.

Question 2

The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?

A) Initiate a game of peek-a-boo.
B) Ask the infant's father to place the infant on the examination table.
C) Talk softly to the infant while taking him from his father.
D) Undress the infant while he is still sitting on his father's lap.

Answer 2

Initiate a game of peek-a-boo.

Question 3

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

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

Answer 3

History

Question 4

Which is considered a block to effective communication?

A) Using silence
B) Using clichés
C) Directing the focus
D) Defining the problem

Question 5

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

A) Presence of the child's parent
B) Child's physical condition
C) Child's developmental level
D) Child's nonverbal behaviors

Question 6

Which data should be included in a health history?

A) Review of systems
B) Physical assessment
C) Growth measurements
D) Record of vital signs

Question 7

Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?

A) Focus communication on the child.
B) Use easy analogies when possible.
C) Explain experiences of others to the child.
D) Assure the child that communication is private.

Question 8

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

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 9

The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful?

A) Recommend that the child keep a diary.
B) Provide supplies for the child to draw a picture.
C) Suggest that the parent read fairy tales to the child.
D) Ask the parent if the child is always uncommunicative.

Question 10

The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?

A) Appropriate because of child's age
B) Appropriate, but the mother may be uncomfortable
C) Inappropriate because of child's age
D) Inappropriate because child is same sex as mother

Question 11

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

A) Lacking in protein
B) Indicating they live in poverty
C) Providing sufficient amino acids
D) Needing enrichment with meat and milk

Question 12

When the nurse interviews an adolescent, which is especially important?

A) Focus the discussion on the peer group.
B) Allow an opportunity to express feelings.
C) Use the same type of language as the adolescent.
D) Emphasize that confidentiality will always be maintained.

Question 13

The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?

A) Request a detailed listing of symptoms.
B) Ask the adolescent, "Why did you come here today?"
C) Interview the parent away from the adolescent to determine the chief complaint.
D) Use what the adolescent says to determine, in correct medical terminology, what the problem is.

Question 14

With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?

A) 10th percentile
B) 75th percentile
C) 85th percentile
D) 95th percentile

Question 15

Where in the health history does a record of immunizations belong?

A) History
B) Present illness
C) Review of systems
D) Physical assessment

Question 16

Rectal temperatures are indicated in which situation?

A) In the newborn period
B) Whenever accuracy is essential
C) Rectal temperatures are never indicated
D) When rapid temperature changes are occurring

Question 17

Which parameter correlates best with measurements of total muscle mass?

A) Height
B) Weight
C) Skinfold thickness
D) Upper arm circumference

Question 18

The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?

A) Introduce him- or herself.
B) Make the family comfortable.
C) Give assurance of privacy.
D) Explain the purpose of the interview.

Question 19

What is the earliest age at which a satisfactory radial pulse can be taken in children?

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

Question 20

An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?

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 21

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

Question 22

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

Question 23

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

Question 24

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.

Question 25

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

Question 26

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.

Question 27

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

Question 28

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

Question 29

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.

Question 30

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.

Question 31

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

Question 32

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

Question 33

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

Question 34

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

Question 35

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.

Question 36

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.

Question 37

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

Question 38

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 39

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.

Question 40

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

Question 41

The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences?

A) The parent feels inferior to the nurse.
B) The parent is showing respect for the nurse.
C) The parent is embarrassed to seek health care.
D) The parent feels responsible for her child's illness.

Question 42

The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.)

A) Wheezes
B) Crackles
C) Vesicular
D) Bronchial
E) Bronchovesicular

Question 43

The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.)

A) Ashen gray areas
B) A well-defined light reflex
C) A small, round, concave spot near the center of the drum
D) The tympanic membrane is a nontransparent grayish color
E) A whitish line extending from the umbo upward to the margin of the membrane

Question 44

The nurse is aware that skin turgor best estimates what?

A) Perfusion
B) Adequate hydration
C) Amount of body fat
D) Amount of anemia

Question 45

The nurse understands that blocks to therapeutic communication include what? (Select all that apply.)

A) Socializing
B) Use of silence
C) Using clichés
D) Defending a situation
E) Using open-ended questions

Question 46

The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.)

A) S4 heart sound
B) S3 heart sound
C) Grade II murmur
D) S1 louder at the apex of the heart
E) S2 louder than S1 in the aortic area

Question 47

The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

A) Lightly brush the palate with a cotton swab.
B) Perform the examination in front of a mirror.
C) Let the child examine someone else's mouth first.
D) Have the child breathe deeply and hold his or her breath.
E) Use a tongue blade to help the child open his or her mouth.

Question 48

Which are effective auscultation techniques? (Select all that apply.)

A) Ask the child to breathe shallowly.
B) Apply light pressure on the chest piece.
C) Use a symmetric and orderly approach.
D) Place the stethoscope over one layer of clothing.
E) Warm the stethoscope before placing it on the skin.

Question 49

Which action should the nurse implement when taking an axillary temperature?

A) Take the temperature through one layer of clothing.
B) Add a degree to the result when recording the temperature.
C) Place the tip of the thermometer under the arm in the center of the axilla.
D) Hold the child's arm away from the body while taking the temperature.