Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent My Nursing Test Banks

Chapter 28: The Complete Physical Assessment: Infant, Child, and Adolescent

Jarvis: Physical Examination & Health Assessment, 7th Edition

MULTIPLE CHOICE

1. A 5-year-old child is in the clinic for a checkup. The nurse would expect him to:

a.

Need to be held on his mothers lap.

b.

Be able to sit on the examination table.

c.

Be able to stand on the floor for the examination.

d.

Be able to remain alone in the examination room.

ANS: B

At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parents lap.

DIF: Cognitive Level: Understanding (Comprehension) REF: p. 794

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

2. Which statement is true regarding the recording of data from the history and physical examination?

a.

Use long, descriptive sentences to document findings.

b.

Record the data as soon as possible after the interview and physical examination.

c.

If the information is not documented, then it can be assumed that it was done as a standard of care.

d.

The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient.

ANS: B

The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions.

DIF: Cognitive Level: Applying (Application) REF: p. 784

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

3. When assessing the neonate, the nurse should test for hip stability with which method?

a.

Eliciting the Moro reflex

b.

Performing the Romberg test

c.

Checking for the Ortolani sign

d.

Assessing the stepping reflex

ANS: C

The nurse should test for hip stability in the neonate by testing for the Ortolani sign. The other tests are not appropriate for testing hip stability.

DIF: Cognitive Level: Applying (Application) REF: p. 791

MSC: Client Needs: Health Promotion and Maintenance

4. A female patient tells the nurse that she has four children and has had three pregnancies. How should the nurse document this?

a.

Gravida 3, para 4

b.

Gravida 4, para 3

c.

This information cannot be documented using the terms gravida and para.

d.

The patient seems to be confused about how many times she has been pregnant.

ANS: A

Gravida refers to the number of pregnancies, and para refers to the number of children. One pregnancy was with twins.

DIF: Cognitive Level: Applying (Application) REF: p. 807

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

5. The nurse is documenting the assessment of an infant. During the abdominal assessment, the nurse noticed a very loud splash auscultated over the upper abdomen when the nurse rocked her from side to side. This finding would indicate:

a.

Epigastric hernia.

b.

Pyloric obstruction.

c.

Hypoactive bowel sounds.

d.

Hyperactive bowel sounds.

ANS: D

A succussion splash, which is unrelated to peristalsis, is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach as observed with pyloric obstruction or large hiatus hernia (see Chapter 21).

DIF: Cognitive Level: Analyzing (Analysis) REF: p. 572

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

6. Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?

a.

Testing for Ortolani sign

b.

Assessment for stereognosis

c.

Blood pressure measurement

d.

Assessment for the presence of the startle reflex

ANS: A

Until the age of 12 months, the infant should be assessed for Ortolani sign. If Ortolani sign is present, then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child.

DIF: Cognitive Level: Applying (Application) REF: p. 610

MSC: Client Needs: Safe and Effective Care Environment: Management of Care

Leave a Reply