Question 1

Which of the following data would be included in a health history? (Select all that apply.)

Accepted Answer

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

Question 2

A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her 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 is tested separately. Each 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

A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?

Accepted Answer

With older children, usually those older than 3 years of age, the canal curves downward and forward. Therefore, pull the pinna up and back during otoscopic examinations. In infants, the canal curves upward. Therefore, pull the pinna down and back to straighten the canal. Pulling the pinna straight back or straight up will not open the inner ear canal.

Question 4

At about what age does the Babinski sign disappear?

Accepted Answer

The presence of the Babinski reflex after about age 1 year, when walking begins, is abnormal. Four to 6 months is too young for the disappearance of the Babinski reflex. Persistence of the Babinski reflex requires further evaluation.

Question 5

Where is the appropriate placement of a tongue blade for assessment of the mouth and throat?

Accepted Answer

Side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement in the center back area of the tongue will elicit the gag reflex. Against the soft palate and on the lower jaw are not appropriate places for the tongue blade.

Question 6

A nurse is performing an assessment on a school-age child. Which findings suggest the child is getting an excess of vitamin A? (Select all that apply.)

Accepted Answer

Excess vitamin A can cause delayed sexual development, pruritus, and jaundice. Edema is seen with excess sodium. Paresthesia occurs with excess riboflavin.

Question 7

What is an appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child?

Accepted Answer

Conventional audiometry is a behavioral test that measures auditory thresholds in response to speech and frequency-specific stimuli presented through earphones. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.

Question 8

During examination of a toddler's extremities, the nurse notes that the child is bowlegged. What should the nurse recognize regarding this finding?

Accepted Answer

Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk. It usually persists until all 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-American children.

Question 9

Which is the most appropriate vision acuity test for a child who is in preschool?

Accepted Answer

The HOTV test consists of a wall chart of these letters. The child is asked to point to a corresponding card when the examiner selects one of the letters on the chart. The cover test determines ocular alignment. The Ishihara test is used for the detection of color blindness. The Snellen letter chart is usually used for older children.

Question 10

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. One to 2 months is too young for this developmental milestone. If the infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed.

Question 11

Which figure depicts a nurse performing a test for the triceps reflex?

Accepted Answer

To test the triceps reflex, the child is placed supine, with the forearm resting over the chest and the triceps tendon is struck with the reflex hammer. The other figures depict tests for biceps reflex (slightly above the antecubital space) patellar (knee), and Achilles (behind the foot).

Question 12

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)

Accepted Answer

When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English.

Question 13

A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess?

Accepted Answer

Asthma causes bronchoconstriction and narrowed passageways. Wheezes are produced as air passes through narrowed passageways. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture.

Question 14

While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?

Accepted Answer

Cheyne-Stokes respirations are a pattern of respirations that gradually increase in rate and depth, with periods of apnea. Dyspnea is defined as distress during breathing. Tachypnea is an increased respiratory rate. In seesaw respirations, the chest falls on inspiration and rises on expiration.

Question 15

The nurse has a 2-year-old boy sit in "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 by this method. This position is used for inhibiting the cremasteric reflex. Privacy should always be provided for children.

Question 16

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 17

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. What criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply.)

Accepted Answer

Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. 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 18

A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?

Accepted Answer

Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. These are the sounds expected to be heard in a child with a ventricular septal defect because of the abnormal opening between the ventricles. S? is a normal heart sound sometimes heard in children. S? is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S?, which widens on inspiration. It is a significant normal finding.

Question 19

The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?

Accepted Answer

Pulses are the fluid wave through the blood vessel as a result of each heartbeat. Therefore, they should be the same.

Question 20

How does the nurse assess a child's capillary refill time?

Accepted Answer

Capillary refill 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 refill time.

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