Question 1

At what age should the nurse expect the anterior fontanel to close?

Accepted Answer

The anterior fontanel normally closes between ages 12 and 18 months. Two to 8 months is too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes between ages 2 and 8 months, the child should be referred for further evaluation.

Question 2

The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?

Accepted Answer

Jaundice is defined as the yellow staining of the skin, usually by bile pigments. Yellow staining is not a normal appearance of the skin. Erythema is redness that results from increased blood flow to the area. Ecchymosis is large, diffuse areas, usually black and blue, caused by hemorrhage of blood into the skin.

Question 3

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?

Accepted Answer

Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.

Question 4

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. Which is the most appropriate action?

Accepted Answer

Hyperextension of the child's head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation; it is not descriptive of head lag. The pain is indicative of meningeal irritation. No indication of injury is present.

Question 5

A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

Accepted Answer

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 in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight.

Question 6

Which tool measures body fat most accurately?

Accepted Answer

Calipers are used to measure skinfold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.

Question 7

The nurse is using the Centers for Disease Control and Prevention (CDC) growth chart for an African-American child. Which statement should the nurse consider?

Accepted Answer

The CDC growth charts can serve as reference guides for all racial or ethnic groups. US African-American children were included in the sample population. The growth chart can be used with the perspective that different groups of children have varying normal distributions on the growth curves. No correction factor exists.

Question 8

Which following parameters correlates best with measurements of the body's total protein stores?

Accepted Answer

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

Question 9

Pulses can be graded according to certain criteria. Which is a description of a normal pulse?

Accepted Answer

A normal pulse is described as +3. A pulse that is easy to palpate and not easily obliterated with pressure is considered normal. A pulse graded 0 is not palpable. A pulse graded +1 is difficult to palpate, thready, weak, and easily obliterated with pressure. A pulse graded +2 is difficult to palpate and may be easily obliterated with pressure.

Question 10

The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school-age child. What is the purpose of doing this?

Accepted Answer

Measurement of skinfold thickness is an indicator of body fat. Arm circumference is an indirect measure of muscle mass. The accuracy of weight measurement should be verified with a properly balanced scale. Body fat is just one indicator of weight.

Question 11

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 12

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 apical pulse can be used for assessment at these ages.

Question 13

The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. How should this action be interpreted?

Accepted Answer

The older school-age child should be given the option of having the parent present or not. During the examination, the nurse should respect the child's need for privacy. Although the question was appropriate for the child's age, the mother is responsible for making decisions for the child. It is appropriate because of the child's age. During the examination, the nurse must respect the child's privacy. The child should help determine who is present during the examination.

Question 14

Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?

Accepted Answer

The axillary sensor measures the infrared heat energy radiating from the axilla. It can be used on wet skin, in incubators, or under radiant warmers. Ear thermometry does not show sufficient correlation with established methods of measurement. It should not be used when body temperature must be assessed with precision. Mercury thermometers should never be used. The release of mercury, should the thermometer be broken, can cause harmful vapors. Rectal temperatures should be avoided unless no other suitable way exists for the temperature to be measured.

Question 15

A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child?

Accepted Answer

Parents can remove clothing, and the child can remain on the parent's lap. The nurse should use minimal physical contact initially to gain the child's cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for toddlers.

Question 16

A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?

Accepted Answer

Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference before age 1. Chest circumference is larger than head circumference at 11ea1402_15da_9d2c_8185_4d0165b7de4d_TB1180_11 to 3 years.

Question 17

Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age?

Accepted Answer

Binocularity is usually achieved by ages 3 to 4 months. 1 month is too young. If binocularity is not achieved by ages 6 to 12 months, the child must be observed for strabismus.

Question 18

A nurse is preparing to test a school-age child's vision. Which eye chart should the nurse use?

Accepted Answer

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

Question 19

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

Accepted Answer

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.

Question 20

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

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 are not usually indicative of cancer. A scalp infection would usually not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed.

Quiz 4: Communication and Physical Assessment of the Child and Family