Chapter 5 My Nursing Test Banks

Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 5th Edition Test Bank
Chapter 5

Question 1

Type: MCSA

The nurse is taking a health history from a family of a 3-year-old child. The statement by the nurse that would be most likely to establish rapport and elicit an accurate response from the family is

1. Does any member of your family have a history of asthma, heart disease, or diabetes?

2. Hello, I would like to talk with you and get some information on you and your child.

3. Tell me about the concerns that brought you to the clinic today.

4. You will need to fill out these forms; make sure that the information is as complete as possible.

Correct Answer: 3

Rationale 1: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parents perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Rationale 2: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parents perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Rationale 3: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parents perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Rationale 4: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parents perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Apply communication strategies to improve the quality of historical data collected.

Question 2

Type: MCSA

When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old?

1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was.

2. Ask the child to repeat his address.

3. Ask the child to say a poem and listen to the childs speech articulation.

4. Have the child point to various parts of the body as the you name them.

Correct Answer: 2

Rationale 1: Repeating the name of an object after 510 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Rationale 2: Repeating the name of an object after 510 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Rationale 3: Repeating the name of an object after 510 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Rationale 4: Repeating the name of an object after 510 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 01. Describe the elements of a health history for an infant and child at different ages.

Question 3

Type: SEQ

Put the following nursing assessments of a toddler in the best order for the nurse to proceed:

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Examination of eyes, ears, and throat.

Choice 2. Auscultation of chest.

Choice 3. Palpation of abdomen.

Choice 4. Developmental assessment.

Correct Answer: 4,2,3,1

Rationale 1: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Rationale 2: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Rationale 3: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Rationale 4: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 04. Demonstrate the differences in sequence of the physical assessment for infants, children, and adolescents.

Question 4

Type: MCSA

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. The organ system that the nurse would suspect as having an ongoing disease process is

1. Cardiac.

2. Respiratory.

3. Gastrointestinal.

4. Genitourinary.

Correct Answer: 3

Rationale 1: This infants sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 2: This infants sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 3: This infants sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 4: This infants sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 5

Type: MCSA

A nurse caring for a 9-year-old notices some swelling in the childs ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Due to these physical findings, the nurse would be most concerned with assessing

1. Skin integrity, especially in the lower extremities.

2. Urine output.

3. Level of consciousness.

4. Range of motion and ankle mobility.

Correct Answer: 2

Rationale 1: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 2: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 3: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 4: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 6

Type: MCSA

A new mother is worried about a soft spot on the top of her newborn infants head. The nurse informs her that this is a normal physical finding called the anterior fontanel and that it will remain open until

1. 2 to 3 months of age.

2. 6 to 9 months of age.

3. 12 to 18 months of age.

4. Approximately 2 years of age.

Correct Answer: 3

Rationale 1: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Rationale 2: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Rationale 3: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Rationale 4: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 01. Describe the elements of a health history for an infant and child at different ages.

Question 7

Type: MCSA

While inspecting a 5-year-old childs ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, the vital-sign parameter that the nurse would be most concerned with would be

1. Temperature.

2. Heart rate.

3. Respirations.

4. Blood pressure.

Correct Answer: 1

Rationale 1: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Rationale 2: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Rationale 3: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Rationale 4: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 8

Type: MCMA

A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical exam the nurse would expect which of the following findings?

Standard Text: Select all that apply.

1. Wheezing.

2. Increased tactile fremitus.

3. Decreased vocal resonance.

4. Decreased tactile fremitus.

5. Bronchophony.

Correct Answer: 1,3,4

Rationale 1: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 2: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 3: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 4: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 5: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 9

Type: MCSA

The nurse is caring for a newly admitted infant diagnosed with failure to thrive. The nurse begins to implement physician orders by taking blood pressures in all four extremities. The nurse recognizes that the physician suspects which congenital cardiac defect?

1. Tetralogy of Fallot.

2. Pulmonary atresia.

3. Coarctation of the aorta.

4. Ventricular septal defect.

Correct Answer: 3

Rationale 1: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Rationale 2: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Rationale 3: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Rationale 4: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 10

Type: MCSA

During an examination, a nurse asks a 5-year-old child to repeat his address. The nurse is most likely evaluating

1. Recent memory.

2. Language development.

3. Remote memory.

4. Social-skill development.

Correct Answer: 3

Rationale 1: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the childs language development, and assessing how he interacts with others evaluates social-skill development.

Rationale 2: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the childs language development, and assessing how he interacts with others evaluates social-skill development.

Rationale 3: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the childs language development, and assessing how he interacts with others evaluates social-skill development.

Rationale 4: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the childs language development, and assessing how he interacts with others evaluates social-skill development.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 02. Apply communication strategies to improve the quality of historical data collected.

Question 11

Type: MCSA

A very concerned 14-year-old boy presents to the clinic because of an enlargement of his left breast. Except for the breast enlargement, the rest of the history and physical was reported as normal. The most appropriate intervention for the nurse to implement next would be to inform the child that

1. A pediatric endocrine consult is being arranged.

2. The health practitioner is arranging a surgical consult for their son.

3. This is a normal finding in adolescent males and that the breast tissue generally regresses by the time of full sexual maturity.

4. His condition is related to a high fat diet and that limiting fat intake usually will resolve the enlargement over a period of a couple of months.

Correct Answer: 3

Rationale 1: Gynecomastia, or breast enlargement, is a normal finding in adolescent males, appearing first around 14 years of age and typically disappearing by full sexual maturity.

Rationale 2: Gynecomastia, or breast enlargement, is a normal finding in adolescent males, appearing first around 14 years of age and typically disappearing by full sexual maturity.

Rationale 3: Gynecomastia, or breast enlargement, is a normal finding in adolescent males, appearing first around 14 years of age and typically disappearing by full sexual maturity. appearing first around 14 years of age and typically disappearing by full sexual maturity.

Rationale 4: Gynecomastia, or breast enlargement, is a normal finding in adolescent males, appearing first around 14 years of age and typically disappearing by full sexual maturity.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 06. Determine the sexual maturity rating of males and females based upon physical signs of secondary sexual characteristics present.

Question 12

Type: MCSA

The nurse is completing a physical examination of a 4-year-old child. The best position to place the child in for assessment of the genitalia would be:

1. Frog leg position.

2. Right side-lying.

3. Supine, legs at a 50 degree angle.

4. Prone position, knees drawn up under body.

Correct Answer: 1

Rationale 1: Having the child lie supine, flexing her knees and pulling them up to a frog-legged position allows for accurate assessment of the genitalia and is the more well tolerated position in the majority of children.

Rationale 2: Having the child lie supine, flexing her knees and pulling them up to a frog-legged position allows for accurate assessment of the genitalia and is the more well tolerated position in the majority of children.

Rationale 3: Having the child lie supine, flexing her knees and pulling them up to a frog-legged position allows for accurate assessment of the genitalia and is the more well tolerated position in the majority of children.

Rationale 4: Having the child lie supine, flexing her knees and pulling them up to a frog-legged position allows for accurate assessment of the genitalia and is the more well tolerated position in the majority of children.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 06. Determine the sexual maturity rating of males and females based upon physical signs of secondary sexual characteristics present.

Question 13

Type: MCSA

During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be:

1. Soles are flat with prominent fat pads.

2. Positive Babinski reflex.

3. Metatarsus varus.

4. Asymmetric thigh and gluteal folds.

Correct Answer: 4

Rationale 1: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Rationale 2: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Rationale 3: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Rationale 4: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 14

Type: MCSA

The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first?

1. A child with a temperature of 101 degrees F.

2. A child who has stridor.

3. A child who has absent Babinskis sign.

4. A child who has a pot belly appearance.

Correct Answer: 2

Rationale 1: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinskis sign and the pot-bellied child are normal.

Rationale 2: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinskis sign and the pot-bellied child are normal.

Rationale 3: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinskis sign and the pot-bellied child are normal.

Rationale 4: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinskis sign and the pot-bellied child are normal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 15

Type: MCSA

The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to:

1. Hear a quiet but easily heard murmur.

2. Hear a moderately loud murmur without a palpable thrill.

3. Hear a very loud murmur with easily palpable thrill.

4. Listen without a stethoscope and hear a murmur at chest wall.

Correct Answer: 2

Rationale 1: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Rationale 2: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Rationale 3: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Rationale 4: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 07. Analyze findings from the assessment of multiple systems and recognize signs indicating the presence of a health condition.

Question 16

Type: MCSA

The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the childs abdomen where the tape measure should be placed for an accurate abdominal girth.

1. Just above the umbilicus, around the largest circumference of the abdomen.

2. Below the umbilicus.

3. Just below the sternum.

4. Just above the pubic bone.

Correct Answer: 1

Rationale 1: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Rationale 2: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Rationale 3: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Rationale 4: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 05. Modify physical assessment techniques according to the age and developmental stage of the child.

Ball/Bindler/Cowen, Principles of Pediatric Nursing 5th Ed. Test Bank

Copyright 2012 by Pearson Education, Inc.

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