Question 1

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

Accepted Answer

The tailor position stretches the muscle responsible for the cremasteric reflex.This prevents its contraction,which pulls the testes into the pelvic cavity.Undescended testes cannot be predictably palpated.Inguinal hernias are not detected with this method.This position is used for inhibiting the cremasteric reflex.Privacy should always be provided for children.

Question 2

The nurse asks a preschool-age child to do the "finger-to-nose" test.What is the nurse testing for?

Accepted Answer

The finger-to-nose-test is an indication of cerebellar function.This test checks balance and coordination.Each deep tendon reflex and sense is tested separately.Although this test enables the nurse to evaluate the child's ability to follow directions,it is used primarily for cerebellar function.

Question 3

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup.Which criteria should the nurse use to determine the appropriate-size blood pressure cuff?

Accepted Answer

The cuff will usually have a bladder length that is 80 to 100% of the upper arm circumference.Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference is appropriate,not 80%.This size cuff will most accurately reflect measured radial artery pressure.The name of the cuff is a representative size that may not be suitable for any individual child.Choosing a cuff by limb circumference more accurately reflects arterial pressure than choosing a cuff by length.

Question 4

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Accepted Answer

Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood.S₁ is the closure of the tricuspid and mitral valves,and S₂ is the closure of the pulmonic and aortic valves;both are considered normal heart sounds.S₃ is a normal heart sound sometimes heard in children.S₄ is rarely heard as a normal heart sound,and a medical evaluation is required if the nurse hears it.Physiological splitting is the distinction of the two sounds in S₂,which widens on inspiration.It is a significant normal finding.

Question 5

During a funduscopic examination of a school-aged child,the nurse notes a brilliant,uniform red reflex in both eyes.How would the nurse document this finding?

Accepted Answer

A brilliant,uniform red reflex is an important normal and expected finding.It rules out many serious defects of the cornea,aqueous chamber,lens,and vitreous chamber.

Question 6

What is the most frequently used test for measuring visual acuity?

Accepted Answer

The Snellen letter chart,which consists of lines of letters of decreasing size,is the most frequently used test for visual acuity.Single cards (Denver-letter E;Allen-pictures)are used for children age 2 years and older who are unable to use the Snellen letter chart.The Ishihara vision test is used for colour vision.

Question 7

The nurse is testing an infant's visual acuity.By what age should the infant be able to fix on and follow a target?

Accepted Answer

Visual fixation and following a target should be present by ages 3 to 4 months.Ages 1 to 2 months are too young for this developmental milestone.If the infant is not able to fix and follow by 6 months of age,further ophthalmological evaluation is needed.

Question 8

Binocularity is normally present by what age?

Accepted Answer

Binocularity is usually achieved by ages 3 to 4 months.One month is too young for binocularity.If binocularity is not achieved by 6 months,the child must be observed for strabismus.

Question 9

What 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?

Accepted Answer

Vesicular breath sounds are heard over the entire surface of 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 trachea and bronchi bifurcate.

Question 10

When palpating a child's cervical lymph nodes,the nurse notes that they are tender,enlarged,and warm.What is the best explanation for this finding?

Accepted Answer

Small,nontender nodes are normal.Tender,enlarged,and warm lymph nodes may indicate infection or inflammation close to their location.Tender lymph nodes do not usually indicate cancer.A scalp infection usually does not cause inflamed lymph nodes.The lymph nodes close to the site of inflammation or infection would be inflamed.

Question 11

Which data are included in a health history?

Accepted Answer

The review of systems,sexual history,nutritional assessment,and family medical history are part of the health history.Physical assessment,vital signs,and growth measurements are components of the physical examination.

Question 12

What is the correct order of the steps for examining the abdomen?

Accepted Answer

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.

Question 13

When teaching new parents about their infants' anterior fontanel,the nurse tells them that it will close at which age?

Accepted Answer

The expected closure of the anterior fontanel occurs between 12 and 18 months;2 through 8 months is too soon.If it closes at these earlier ages,the child should be referred for further evaluation.

Question 14

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

Accepted Answer

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

Question 15

The nurse has just started assessing a young child who is febrile and appears very ill.There is hyperextension of the child's head (opisthotonos),with pain on flexion.What is the priority action?

Accepted Answer

These symptoms indicate meningeal irritation and the child needs immediate evaluation.Continuing the assessment is not necessary.No indication of injury is present.This is not descriptive of head lag.

Question 16

What is the appropriate placement for a tongue blade to assess the mouth and throat?

Accepted Answer

The side of the tongue is the correct position.It avoids the gag reflex,yet allows the nurse good visibility.Placement on the centre back area of the tongue elicits the gag reflex.Against the soft palate and on the lower jaw are also not appropriate places for the tongue blade.

Question 17

How should the nurse assess a child's capillary filling time?

Accepted Answer

Capillary filling 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 filling time.

Question 18

By what age do the head and chest circumferences generally become equal?

Accepted Answer

Head circumference begins larger than chest circumference.Between the ages of 1 and 2 years,they become approximately equal.Head circumference is larger than chest circumference at 1 month and 6 to 9 months.Chest circumference is larger than head circumference at age 2.5 to 3 years.

Question 19

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

Accepted Answer

Satisfactory radial pulses can be used in children older than 2 years.In infants and young children the apical pulse is more reliable.The radial pulse can be used for assessment at ages 3 and 6 years.

Question 20

During an examination of a toddler's extremities,the nurse notes that the child is bowlegged.How should the nurse document this finding?

Accepted Answer

Lateral bowing of the tibia (bowlegged)is common in toddlers when they begin to walk,not an abnormal finding.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 Canadian children.

Quiz 33: Communication, History, Physical, and Developmental Assessment