Chapter 33: Physical Assessment of Children My Nursing Test Banks

Chapter 33: Physical Assessment of Children

Test Bank

MULTIPLE CHOICE

1. The nurse percussing over an empty stomach expects to hear which sound?

a.

Tympany

b.

Resonance

c.

Flatness

d.

Dullness

ANS: A

Feedback

A

Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel.

B

Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs.

C

Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle.

D

Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver.

PTS: 1 DIF: Cognitive Level: Application REF: p. 806 | Box 33-1

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

2. You are the nurse admitting a toddler to the pediatric infectious disease unit. What is the single most important component of the childs physical examination?

a.

Assessment of heart and lungs

b.

Measurement of height and weight

c.

Documentation of parental concerns

d.

Obtaining an accurate history

ANS: D

Feedback

A

Heart and lung assessment is not as important as an accurate history.

B

A single measurement of height and weight is not as significant as determining growth over time. The childs growth pattern can be elicited from the history.

C

Documentation of parental concerns is not as relevant to the physical examination as an accurate history.

D

An accurate history is most helpful in identifying problems and potential problems.

PTS: 1 DIF: Cognitive Level: Application REF: p. 807

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

3. In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea?

a.

Review of systems

b.

Chief complaint

c.

Lifestyle and life patterns

d.

Health history

ANS: B

Feedback

A

The review of systems includes past health functions of body systems.

B

The chief complaint is documented using the childs or parents words for the reason the child was brought to the health care center.

C

Lifestyle and life patterns include the childs interaction with the social, psychological, physical, and cultural environment.

D

Health history includes birth history, growth and development, common childhood illnesses, immunizations, hospitalizations, injuries, and allergies.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 808 | Box 33-4

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

4. Which choice includes the components of a complete pediatric history?

a.

Statistical information, client profile, health history, family history, review of systems, lifestyle and life patterns

b.

Vital signs, chief complaint, and list of previous problems

c.

Chief complaint, including body location, quality, quantity, timeframe, and alleviating and aggravating factors

d.

Pertinent developmental and family information

ANS: A

Feedback

A

The identified items are included in a complete pediatric history.

B

Vital signs, chief complaint, and list of previous problems do not constitute a complete history.

C

A problem-oriented history includes specific information about the chief complaint.

D

Pertinent developmental and family information are part of the complete history.

PTS: 1 DIF: Cognitive Level: Application REF: p. 807 | Box 33-3

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

5. The nurse is performing a comprehensive physical examination on a young child in the hospital. At what age can the nurse expect a childs head and chest circumferences to be almost equal?

a.

Birth

b.

6 months

c.

1 year

d.

3 years

ANS: C

Feedback

A

Head circumference is larger than chest circumference until approximately 12 months of age.

B

Chest circumference is smaller than head circumference until approximately 1 year of age.

C

Head and chest measurements are almost equal at 1 year of age.

D

By 3 years of age, the chest circumference exceeds the head circumference.

PTS: 1 DIF: Cognitive Level: Application REF: p. 811

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

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

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

Feedback

A

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.

B

The child is not exhibiting anxiety, just requesting clarification of what will be occurring.

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.

D

The nurse must explain how the blood pressure cuff works so that the child can then observe during the procedure.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 805

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

7. Which chart should the nurse use to assess the visual acuity of an 8-year-old child?

a.

Lea chart

b.

Snellen chart

c.

HOTV chart

d.

Tumbling E chart

ANS: B

Feedback

A

The Lea chart tests vision using four different symbols designed for use with preschool children.

B

The Snellen chart is used to assess the vision of children older than 6 years of age.

C

The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years.

D

The tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 817 | Box 33-8

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

8. Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child?

a.

Ask the parent to quiet the child so the nurse can listen.

b.

Auscultate breath sounds and chart that the child was crying.

c.

Encourage the child to play with the stethoscope to distract and to calm down before auscultating.

d.

Document that data are not available because of noncompliance.

ANS: C

Feedback

A

Asking a parent to quiet the child may or may not work.

B

Auscultating while the child is crying typically results in less than optimal data.

C

Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made.

D

Documenting that the child is not compliant is not appropriate. An assessment needs to be completed.

PTS: 1 DIF: Cognitive Level: Application REF: p. 805

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

9. The nurse is obtaining vital signs on a 1-year-old child. What is the most appropriate site for assessing the pulse rate?

a.

Apical

b.

Radial

c.

Carotid

d.

Femoral

ANS: A

Feedback

A

Apical pulse rates are taken in children younger than 2 years.

B

Radial pulse rates may be taken in children older than 2 years.

C

It is difficult to palpate the carotid pulse in an infant.

D

The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infants pulse rate.

PTS: 1 DIF: Cognitive Level: Application REF: p. 809

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

10. A nurse is reviewing pediatric physical assessment techniques. Which statement about performing a pediatric physical assessment is correct?

a.

Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise.

b.

The physical examination should be done with parents in the examining room for children of any age.

c.

Measurement of head circumference is done until the child is 5 years old.

d.

The physical examination is done only when the child is cooperative.

ANS: A

Feedback

A

Physical assessment usually proceeds from head to toe; however, developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data.

B

Having parents in the examining room with adolescents is not appropriate.

C

Head circumference is routinely measured until 36 months of age.

D

Children will not always be cooperative during the physical examination. The examiner will need to incorporate communication and play techniques to facilitate cooperation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 804

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

11. What term should be used in the nurses documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration?

a.

Pleural friction rub

b.

Bronchovesicular sounds

c.

Crackles

d.

Wheeze

ANS: C

Feedback

A

A pleural friction rub has a grating, coarse, low-pitched sound.

B

Bronchovesicular sounds are auscultated over mainstem bronchi. They are clear, without any adventitious sounds.

C

Crackles are short, popping, discontinuous sounds heard on inspiration.

D

Wheezes are musical, high-pitched, predominant sounds heard on expiration.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 825 | Table 33-2

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

12. Which strategy is the best approach when initiating the physical examination of a 9-month-old male infant?

a.

Undress the infant and do a head-to-toe examination.

b.

Have the parent hold the child on his or her lap.

c.

Put the infant on the examination table and begin assessments at the head.

d.

Ask the parent to leave because the infant will be upset.

ANS: B

Feedback

A

The head-to-toe approach needs to be modified for the infant. Uncomfortable procedures, such as the otoscopic examination, should be left until last.

B

Infants 6 months and older feel stranger anxiety. It is easier to do most of the examination on the parents lap to lessen anxiety.

C

The infant may feel less fearful if placed in the parents lap or with the parent within visual range if placed on the examining table. The head-to-toe approach is modified for the infant.

D

There is no reason to ask a parent to leave when an infant is being examined. Having the parent with the infant will make the experience less upsetting for the infant.

PTS: 1 DIF: Cognitive Level: Comprehension REF: pp. 804-805

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

13. Which strategy is not always appropriate for pediatric physical examination?

a.

Take the history in a quiet, private place.

b.

Examine the child from head to toe.

c.

Exhibit sensitivity to cultural needs and differences.

d.

Perform frightening procedures last.

ANS: B

Feedback

A

The nurse should collect the childs health history in a quiet, private area.

B

The classic approach to physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner must tailor the physical assessment to the childs age and developmental level.

C

The nurse should always be sensitive to cultural needs and differences among children.

D

When examining children, painful or frightening procedures should be left to the end of the examination.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 804

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

14. Which assessment should the nurse perform last when examining a 5-year-old child?

a.

Heart

b.

Lungs

c.

Abdomen

d.

Throat

ANS: D

Feedback

A

The nurse may proceed from head to toe with preschool-age children. More invasive procedures should be saved until the end of the examination. Assessment of the heart is considered noninvasive.

B

For preschool children, invasive procedures should be left to the end of the examination. Assessment of the lungs is not considered to be frightening.

C

For preschool children, invasive procedures should be left to the end of the examination. Assessment of the abdomen is not considered to be frightening.

D

Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination.

PTS: 1 DIF: Cognitive Level: Application REF: p. 805

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

15. When is the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old girl?

a.

It is not necessary to inspect the genital area.

b.

Examine the genital area first.

c.

After the abdominal assessment.

d.

Do the genital inspection last.

ANS: C

Feedback

A

A visual inspection of all areas of the body is included in a physical examination.

B

Examination of the genital area can be embarrassing. It is not be appropriate to begin the examination of this area.

C

It is best to incorporate the genital assessment into the middle of the examination. This allows ample time for questions and discussion. If possible, proceed from the abdominal area to the genital area.

D

Assessing the genital area earlier in the examination allows more time for the adolescent to ask questions and engage in discussion.

PTS: 1 DIF: Cognitive Level: Application REF: p. 805

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

16. Which measurement is not indicated for a 4-year-old well-child examination?

a.

Blood pressure

b.

Weight

c.

Height

d.

Head circumference

ANS: D

Feedback

A

Blood pressure measurements are taken on all children at every ambulatory visit.

B

Weight is measured at every well-child examination.

C

Height is measured at every well-child examination.

D

Head circumference is measured on all children from birth to 3 years. Children older than 3 years of age with questionable head size or a history of megalocephaly, hydrocephalus, or microcephaly should have their head circumference assessed at every visit. A 4-year-old without a history of these problems does not need his or her head circumference measured.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 810

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

17. The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or violet color. This skin coloration is associated with what?

a.

Cyanosis

b.

Erythema

c.

Vitiligo

d.

Nevi

ANS: B

Feedback

A

Cyanosis in a dark-skinned child appears as a black coloration of the skin.

B

In dark-skinned children, erythema appears as dusky red or violet skin coloration.

C

Vitiligo refers to areas of depigmentation.

D

Nevi are areas of increased pigmentation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 812

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

18. The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed. What does this finding indicate?

a.

This is a normal finding.

b.

This finding indicates premature closure of cranial sutures.

c.

This is abnormal and the child should have a developmental evaluation.

d.

This is an abnormal finding and the child should have a neurologic evaluation.

ANS: A

Feedback

A

The anterior fontanel should be completely closed by 12 to 18 months of age.

B

A closed anterior fontanel at 14 months of age does not indicate premature closure of cranial sutures.

C

This finding is not abnormal and does not necessitate a developmental evaluation.

D

This finding is not abnormal and does not indicate the need for a neurologic examination.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 814

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

19. The nurse is assessing a 4-year-old childs visual acuity. He is planning to attend preschool next week. The results indicate a visual acuity of 20/40 in both eyes. The childs father asks the nurse about his sons results. Which response, if made by the nurse, is correct?

a.

Your child will need a referral to the ophthalmologist before he can attend preschool next week.

b.

Your childs visual acuity is normal for his age.

c.

The results of this test indicate your child may be color blind.

d.

Your child did not pass the screening test. He will need to return within the next few weeks to be reevaluated.

ANS: B

Feedback

A

This is within the normal range for visual acuity at 4 years of age. The 4-year-olds acuity is usually 20/30 to 20/40. There is no need for evaluation by an ophthalmologist at this time.

B

This is the correct response.

C

The childs visual acuity is within normal range for his age. Color vision is evaluated by different methods than visual acuity.

D

This is within the normal range for visual acuity at 4 years of age. The 4-year-olds acuity is usually 20/30 to 20/40. There is no need for further evaluation at this time.

PTS: 1 DIF: Cognitive Level: Application REF: p. 817

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

20. When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered

a.

Unnecessary information, because the child is 3 years old

b.

An important part of the family history

c.

An important part of the childs past growth and development

d.

An important part of the childs review of systems

ANS: C

Feedback

A

Developmental milestones provide important information about the childs physical, social, and neurologic health.

B

The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings should be included in the family history.

C

Information about the attainment of developmental milestones is important to obtain. It provides data about the childs growth and development that should be included in the history.

D

The review of systems does not include the developmental milestones.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 807 | Box 33-3

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

21. Which cranial nerve is assessed when the child is asked to imitate the examiners wrinkled frown, wrinkled forehead, smile, and raised eyebrow?

a.

Accessory

b.

Hypoglossal

c.

Trigeminal

d.

Facial

ANS: D

Feedback

A

To assess the accessory nerve, the examiner palpates and notes the strength of the trapezius and sternocleidomastoid muscles against resistance.

B

To assess the hypoglossal nerve, the examiner asks the child to stick out the tongue.

C

To assess the trigeminal nerve, the child is asked to identify a wisp of cotton on the face. The corneal reflex and temporal and masseter muscle strength are evaluated.

D

The facial nerve is assessed as described in the question.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 834 | Tables 33-4, 33-6

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

22. Which assessment finding is considered a neurologic soft sign in a 7-year-old child?

a.

Plantar reflex

b.

Poor muscle coordination

c.

Stereognostic function

d.

Graphesthesia

ANS: B

Feedback

A

The plantar reflex is a normal response. When the lateral aspect of the sole of the foot is stroked in a movement curving medially from the heel to the ball, the response will be plantar flexion of the toes.

B

Poor muscle coordination is a neurologic soft sign.

C

Stereognostic function refers to the ability to identify familiar objects placed in each hand.

D

Graphesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point.

PTS: 1 DIF: Cognitive Level: Application REF: p. 838 | Box 33-13

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

23. Which parameter correlates best with measurements of the bodys total muscle-mass to fat ratio?

a.

Height

b.

Weight

c.

Skin-fold thickness

d.

Mid arm circumference

ANS: D

Feedback

A

Height is reflective of past nutritional status.

B

Weight is indicative of current nutritional status.

C

Skin-fold thickness is a measurement of the bodys fat content.

D

Mid 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.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 811

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

24. Which tool measures body fat most accurately?

a.

Stadiometer

b.

Calipers

c.

Cloth tape measure

d.

Paper or metal tape measure

ANS: B

Feedback

A

Stadiometers are used to measure height.

B

Calipers are used to measure skin-fold thickness, which is an indicator of body fat content.

C

Cloth tape measures should not be used because they can stretch.

D

Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 811

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

25. When palpating the childs cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?

a.

Some form of cancer

b.

Local scalp infection common in children

c.

Infection or inflammation distal to the site

d.

Infection or inflammation close to the site

ANS: D

Feedback

A

Tender lymph nodes are not usually indicative of cancer.

B

A scalp infection usually does not cause inflamed lymph nodes.

C

The lymph nodes close to the site of inflammation or infection would be inflamed.

D

Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 812

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

26. What 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, S2

b.

S3, S4

c.

Murmur

d.

Physiologic splitting

ANS: C

Feedback

A

These 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.

B

S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required.

C

Murmurs are the sounds that are produced in the heart chambers or major arteries from the purulence of blood flow. Murmurs create a blowing and swooshing sound.

D

Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 824

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

27. Examination of the abdomen is performed correctly by the nurse in which order?

a.

Inspection, palpation, and auscultation

b.

Palpation, inspection, and auscultation

c.

Palpation, auscultation, and inspection

d.

Inspection, auscultation, and palpation

ANS: D

Feedback

A

Palpation is always performed last because it may distort the normal abdominal sounds.

B

Palpation is always performed last because it may distort the normal abdominal sounds.

C

Palpation is always performed last because it may distort the normal abdominal sounds.

D

The correct order of abdominal examination is inspection, auscultation, and palpation.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 828

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

28. The nurse has a 2-year-old boy sit in tailor position during palpation for the testes. What is the rationale for this position?

a.

It prevents cremasteric reflex.

b.

Undescended testes can be palpated.

c.

This tests the child for an inguinal hernia.

d.

The child does not yet have a need for privacy.

ANS: A

Feedback

A

The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its contraction, which pulls the testes into the pelvic cavity.

B

Undescended testes cannot be predictably palpated.

C

Inguinal hernias are not detected by this method. This position is used for inhibiting the cremasteric reflex.

D

Privacy should always be provided for children.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 829

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

29. During examination of a toddlers extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is

a.

Abnormal, requiring 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

Feedback

A

This is an expected finding in toddlers.

B

This is an expected finding in toddlers.

C

Further evaluation is needed if it persists beyond age 2 to 3 years, especially in African-American children.

D

Genu varum (bowlegged) is common in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are well developed.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 831

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance

30. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the finger-to-nose test. The nurse is testing for

a.

Deep tendon reflexes

b.

Cerebellar function

c.

Sensory discrimination

d.

Ability to follow directions

ANS: B

Feedback

A

Each deep tendon reflex is tested separately.

B

The finger-to-nose-test is an indication of cerebellar function. This test checks balance and coordination.

C

Each sense is tested separately.

D

Although this test enables the nurse to evaluate the childs ability to follow directions, it is used primarily for cerebellar function.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 835 | Box 33-11

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

MULTIPLE RESPONSE

1. Which statement about performing a pediatric physical assessment is correct for a school-age child? Select all that apply.

a.

Physical examinations proceed systematically from head to toe.

b.

The physical examination should be done with parents in the waiting room.

c.

Measurement of head circumference is obtained.

d.

The physical examination is done only when the child is cooperative.

e.

Remove clothing and have the child put on an examination gown.

ANS: A, D, E

Feedback

Correct

Physical assessment usually proceeds from head to toe; however if developmental delays exist, considerations dictate that the least threatening assessments be done first to obtain accurate data. School-age children are at a developmental stage when they should be cooperative for the physical examination. Children of this age are usually modest, and an examination gown should be provided.

Incorrect

Having parents in the examining room with adolescents is not appropriate, but is appropriate for children of other age-groups. Parents usually are not kept in the waiting room. Measurement of head circumference is obtained on children 36 months of age or less.

PTS: 1 DIF: Cognitive Level: Application REF: p. 805

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

2. What should the nurse recognize as a possible indicator of child abuse in a 4-year-old child being treated for ear pain at the emergency department on a chilly Christmas Day in New York State? Select all that apply.

a.

The child extends his arms to be hugged by the nurse.

b.

The child is wearing clean, baggy shorts, sandals, and an oversized T-shirt.

c.

The child answers all questions in complete sentences, and smiles afterward.

d.

The child has dirty, broken teeth.

e.

The child states Im so fat when the nurse tells his mother he weighs 25 lb.

ANS: B, D, E

Feedback

Correct

These clothes are inappropriate attire for December in New York State. Even though the clothes are clean, dressing inappropriately for the weather is a potential indicator of child abuse. Clothing that is too large or small for the childs size also requires further evaluation. Dirty, broken teeth are an indicator of potential child abuse. A child who is 4 years old and weighs only 25 lb is thin for his age. Body image distortion (being thin but describing self as fat) is a potential indicator of child abuse. A child who is too thin for his height should also be further evaluated.

Incorrect

Although it may be unusual for this child to want to hugged by the nurse, it is not an indicator of child abuse. Answering questions using complete sentences and smiling is appropriate for a 4-year-old.

PTS: 1 DIF: Cognitive Level: Application REF: p. 807 | Box 33-2

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

3. A nurse is performing an assessment on a newborn. Which vital signs indicate a normal finding for this age group? Select all that apply.

a.

Pulse of 80125 a minute

b.

B/P of systolic 6595 and diastolic 3060

c.

Temperature of 36.537.3 Celsius (axillary)

d.

Temperature of 36.437 Celsius (axillary)

e.

Respirations of 3060 a minute

ANS: B, C, E

Feedback

Correct

The normal vital signs for a newborn are temperature 36.5 to 37.3 Celsius (axillary), pulse rate of 120160 a minute, respiratory rate of 3060 a minute, systolic B/P of 6595, and diastolic B/P of 3062. A temperature of 36.437 Celsius is normal for an older child. A pulse rate of 80125 is normal for a 4-year-old child.

Incorrect

A pulse rate of 80125 per minute and temperature of 36.437 C are both too low for a well-newborn.

PTS: 1 DIF: Cognitive Level: Application REF: p. 808 | Table 33-1

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

4. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? Select all that apply.

a.

Pain with deep palpation of the spinal column

b.

Unequal shoulder heights

c.

The trouser pant leg length appears shorter on one side

d.

Inability to bend at the waist

e.

Unequal waist angles

ANS: B, C, E

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Correct

The assessment findings associated with scoliosis include unequal shoulder heights, trouser pant leg length appearing shorter on one side meaning unequal leg length, and unequal waist angles.

Incorrect

Scoliosis is a nonpainful curvature of the spine so pain is not expected and the child is able to bend at the waist adequately.

PTS: 1 DIF: Cognitive Level: Application REF: p. 832

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

COMPLETION

1. The parents of a preschool child ask the nurse why their child needs to have her eyes tested. The nurse explains that although evaluating the visual acuity in a young child can be difficult, the American Academy of Pediatric recommends that visual acuity testing be assessed on all children beginning no later than age _________ years.

ANS:

3

three

The American Academy of Pediatric recommends that visual acuity testing be assessed on all children beginning no later than age 3 years. Tools available for testing the visual acuity of preschool children include Lea cards, tumbling Es, and the HOTV chart.

PTS: 1 DIF: Cognitive Level: Analysis REF: p. 816

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

TRUE/FALSE

1. The CDC recommends that all health care providers use the World Health Organization (WHO) growth standards to monitor growth for infants and children aged 02 years. For children ages 2 and older the CDC growth chart should be used. These charts are standardized and appropriate for all children. Is this statement true or false?

ANS: F

There are special growth charts available for premature or very low birth weight infants, and children with specific conditions that may affect size and growth (i.e., Down syndrome).

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 811

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

2. An important part of the physical exam is the otoscopic examination of the ear. The ear canal should be straightened prior to visualization. If the child is younger than 3, this is accomplished when the nurse pulls the pinna of the ear down and back. Is this the correct procedure?

ANS: T

If the child is older than 3, the pinna is pulled up and back. As much of the ear canal as possible should be visible before the speculum is inserted into the auditory meatus.

PTS: 1 DIF: Cognitive Level: Application REF: p. 820

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

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