Chapter 04: Communication, Physical, and Developmental Assessment My Nursing Test Banks

Chapter 04: Communication, Physical, and Developmental Assessment

MULTIPLE CHOICE

1. 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.

ANS: A

The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.

DIF: Cognitive Level: Applying REF: p. 91

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

2. Which is considered a block to effective communication?

a.

Using silence

b.

Using clichs

c.

Directing the focus

d.

Defining the problem

ANS: B

Using stereotyped comments or clichs can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention.

DIF: Cognitive Level: Applying REF: p. 94

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

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

a.

Presence of the childs parent

b.

Childs physical condition

c.

Childs developmental level

d.

Childs nonverbal behaviors

ANS: C

The nurse must be aware of the childs developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the childs developmental level and physical condition. Although the childs physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents.

DIF: Cognitive Level: Understanding REF: p. 147

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

4. 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.

ANS: A

Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding.

DIF: Cognitive Level: Understanding REF: p. 96

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

5. The nurses 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 childs fear.

c.

One brief explanation will be enough to reduce the childs fear.

d.

The child is too young to understand what the equipment does.

ANS: A

Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the childs fear. Preschoolers need repeated explanations as reassurance.

DIF: Cognitive Level: Analyzing REF: p. 112

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

6. 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.

ANS: B

Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent.

DIF: Cognitive Level: Understanding REF: p. 96 | p. 97

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

7. The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers 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 infants 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 fathers lap.

ANS: A

Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination.

DIF: Cognitive Level: Applying REF: p. 97

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

8. 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.

ANS: C

School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child so that the child can then observe during the procedure. The nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety in asking how the blood pressure apparatus works, just requesting clarification of what will occur.

DIF: Cognitive Level: Applying REF: p. 96

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

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.

ANS: B

Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childrens inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative.

DIF: Cognitive Level: Applying REF: p. 99

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

10. Which data should be included in a health history?

a.

Review of systems

b.

Physical assessment

c.

Growth measurements

d.

Record of vital signs

ANS: A

A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination.

DIF: Cognitive Level: Remembering REF: p. 100

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

11. 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.

ANS: B

The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help.

DIF: Cognitive Level: Applying REF: p. 99

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

12. 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

ANS: A

The history refers to information that relates to previous aspects of the childs health, not to the current problem. The difficult delivery and prematurity are important parts of the infants history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.

DIF: Cognitive Level: Understanding REF: p. 100

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

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

a.

History

b.

Present illness

c.

Review of systems

d.

Physical assessment

ANS: A

The history contains information relating to all previous aspects of the childs health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status.

DIF: Cognitive Level: Understanding REF: p. 100

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

14. 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.

ANS: B

Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone.

DIF: Cognitive Level: Applying REF: p. 102

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

15. 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

ANS: C

A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.

DIF: Cognitive Level: Applying REF: p. 106

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

16. Which parameter correlates best with measurements of total muscle mass?

a.

Height

b.

Weight

c.

Skinfold thickness

d.

Upper arm circumference

ANS: D

Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the bodys fat content.

DIF: Cognitive Level: Understanding REF: p. 122

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

17. 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 childs age

b.

Appropriate, but the mother may be uncomfortable

c.

Inappropriate because of childs age

d.

Inappropriate because child is same sex as mother

ANS: A

It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination.

DIF: Cognitive Level: Applying REF: p. 112

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

18. 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

ANS: C

Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits.

DIF: Cognitive Level: Understanding REF: p. 117

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

19. 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

ANS: B

Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.

DIF: Cognitive Level: Understanding REF: p. 118

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

20. 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

ANS: B

Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.

DIF: Cognitive Level: Understanding REF: p. 140

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

21. 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.

ANS: B

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.

DIF: Cognitive Level: Applying REF: p. 110

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

22. 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

ANS: C

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

DIF: Cognitive Level: Understanding REF: p. 124

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

23. 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.

ANS: C

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.

DIF: Cognitive Level: Applying REF: pp. 125-126

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

24. The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs 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.

ANS: B

Hyperextension of the childs 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.

DIF: Cognitive Level: Analyzing REF: p. 125 TOP: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

25. 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

ANS: A

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.

DIF: Cognitive Level: Analyzing REF: p. 127

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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.

ANS: B

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.

DIF: Cognitive Level: Understanding REF: p. 127

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

27. 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

ANS: A

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.

DIF: Cognitive Level: Understanding REF: p. 129

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

28. The nurse is testing an infants 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

ANS: C

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.

DIF: Cognitive Level: Applying REF: p. 129

TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

29. 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

ANS: C

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 oclock 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 oclock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal.

DIF: Cognitive Level: Understanding REF: p. 131

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

30. 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

ANS: C

Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the childs 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.

DIF: Cognitive Level: Understanding REF: p. 132

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

31. 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

ANS: B

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.

DIF: Cognitive Level: Applying REF: p. 134

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

32. When assessing a preschoolers 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

ANS: D

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.

DIF: Cognitive Level: Applying REF: p. 135

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

33. When auscultating an infants 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

ANS: C

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.

DIF: Cognitive Level: Analyzing REF: p. 137 TOP: Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

34. 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

ANS: A

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.

DIF: Cognitive Level: Understanding REF: p. 137

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

35. The nurse is assessing a childs 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.

ANS: D

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.

DIF: Cognitive Level: Applying REF: p. 139

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

36. 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

ANS: C

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.

DIF: Cognitive Level: Understanding REF: p. 140

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

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

ANS: D

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.

DIF: Cognitive Level: Understanding REF: pp. 141-142

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

38. 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.

ANS: D

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 childs 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.

DIF: Cognitive Level: Applying REF: p. 142

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

39. During examination of a toddlers 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

ANS: D

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.

DIF: Cognitive Level: Understanding REF: p. 145

TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

40. The nurse is caring for a nonEnglish-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 familys needs.

ANS: C

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 familys needs with the interpreter in English because some family members may understand some English.

DIF: Cognitive Level: Applying REF: p. 94

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Health Promotion and Maintenance

41. 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 childs arm away from the body while taking the temperature.

ANS: C

The thermometer tip should be placed under the arm in the center of the axilla and kept close to the skin, not clothing. The temperature should not be taken through any clothing. The childs arm should be pressed firmly against the side, not held away from the body. The temperature should be recorded without a degree added and designated as being taken by the axillary method.

DIF: Cognitive Level: Applying REF: p. 119

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

42. The nurse is aware that skin turgor best estimates what?

a.

Perfusion

b.

Adequate hydration

c.

Amount of body fat

d.

Amount of anemia

ANS: B

Skin turgor is one of the best estimates of adequate hydration and nutrition. It does not indicate amount of body fat and is not a test for anemia.

DIF: Cognitive Level: Understanding REF: p. 125

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

43. 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 childs illness.

ANS: B

In some ethnic groups, eye contact is avoided. In the Vietnamese culture, an individual may not look directly into the nurses eyes as a sign of respect. The nurse providing culturally competent care would recognize that the other answers listed are not why the parent avoids eye contact with the nurse.

DIF: Cognitive Level: Analyzing REF: p. 93

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1. 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

ANS: B, C, E

Normal findings include the light reflex and bony landmarks. The light reflex is a fairly well-defined, cone-shaped reflection that normally points away from the face. The bony landmarks of the eardrum are formed by the umbo, or tip of the malleus. It appears as a small, round, opaque, concave spot near the center of the eardrum. The manubrium (long process or handle) of the malleus appears to be a whitish line extending from the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation.

DIF: Cognitive Level: Understanding REF: p. 132

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2. 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

ANS: C, D, E

Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds.

DIF: Cognitive Level: Applying REF: p. 137

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3. 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 elses 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.

ANS: A, B, C, D

To encourage a child to open the mouth for examination, the nurse can lightly brush the palate with a cotton swab, perform the examination in front of a mirror, let the child examine someone elses mouth first, and have the child breathe deeply and hold his or her breath. A tongue blade may elicit the gag reflex and should not be used.

DIF: Cognitive Level: Applying REF: p. 134

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4. 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.

ANS: C, E

Effective auscultation techniques include using a symmetric approach and warming the stethoscope before placing it on the skin. Breath sounds are best heard if the child inspires deeply, not shallowly. Firm, not light, pressure should be used on the chest piece. The stethoscope should be placed on the skin, not over clothing.

DIF: Cognitive Level: Understanding REF: p. 137

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5. 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

ANS: A, C, E

S4 is rarely heard as a normal heart sound; it usually indicates the need for further cardiac evaluation. A grade II murmur is not normal; it is slightly louder than grade I and is audible in all positions. S3 is normally heard in some children. Normally, S1 is louder at the apex of the heart in the mitral and tricuspid area, and S2 is louder near the base of the heart in the pulmonic and aortic area.

DIF: Cognitive Level: Applying REF: pp. 139-140

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Physiological Integrity

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

a.

Socializing

b.

Use of silence

c.

Using clichs

d.

Defending a situation

e.

Using open-ended questions

ANS: A, C, D

Blocks to communication include socializing, using clichs, and defending a situation. Use of silence and using open-ended questions are therapeutic communication techniques.

DIF: Cognitive Level: Analyzing REF: p. 94

TOP: Integrated Process: Communication and Documentation

MSC: Client Needs: Psychosocial Integrity

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