Question 1

During a musculoskeletal assessment of a school-age child, a nurse documents which finding as expected?

Accepted Answer

A)  A positive Trendelenburg sign on one side 
B)  Lumbar lordosis, especially in African-American children 
C)  Varus rotation when the knees are greater than 1 inch apart 
D)  Valgus rotation of less than 1 inch with the knees touching 
A)  A positive Trendelenburg sign on one side 
B)  Lumbar lordosis, especially in African-American children 
C)  Varus rotation when the knees are greater than 1 inch apart 
D)  Valgus rotation of less than 1 inch with the knees touching D

Question 2

When assessing an infant, the nurse recognizes which finding requires immediate attention?

Accepted Answer

A)  Cheyne-Stokes type of respiratory pattern 
B)  1:1 anteroposterior to lateral chest diameter 
C)  Stridor and nasal flaring 
D)  Bronchovesicular lung sounds in the periphery 
A)  Cheyne-Stokes type of respiratory pattern 
B)  1:1 anteroposterior to lateral chest diameter 
C)  Stridor and nasal flaring 
D)  Bronchovesicular lung sounds in the periphery C

Question 3

To assess the reflexes of a 5-month-old infant lying supine, the nurse turns the infant's head to the left side so that the chin is over the shoulder. What is the expected response for this reflex?

Accepted Answer

A)  Left arm and leg abduct and the right arm and leg adduct. 
B)  Left arm and leg extend and the right arm and leg flex. 
C)  Infant turns the chin from the left to the right side. 
D)  Infant begins a sucking motion with the lips and tongue. 
A)  Left arm and leg abduct and the right arm and leg adduct. 
B)  Left arm and leg extend and the right arm and leg flex. 
C)  Infant turns the chin from the left to the right side. 
D)  Infant begins a sucking motion with the lips and tongue. B

Question 4

During the assessment of a newborn within hours after birth, a nurse determines which finding as abnormal?

Accepted Answer

A)  Capillary refill time of less than 1 second 
B)  Apical pulse felt at the second intercostal space 
C)  Splitting of heart sounds 
D)  Cyanosis of the hands and feet 
A)  Capillary refill time of less than 1 second 
B)  Apical pulse felt at the second intercostal space 
C)  Splitting of heart sounds 
D)  Cyanosis of the hands and feet

Question 5

The nurse documents which finding as normal after performing the Barlow-Ortolani maneuver on an infant?

Accepted Answer

A)  The clavicles are immobile and without crepitus. 
B)  Each shoulder remains in a "hunched up" position. 
C)  No clicking is noted when the hips are abducted and adducted. 
D)  Both feet are held in the varus position when stroked on the soles. 
A)  The clavicles are immobile and without crepitus. 
B)  Each shoulder remains in a "hunched up" position. 
C)  No clicking is noted when the hips are abducted and adducted. 
D)  Both feet are held in the varus position when stroked on the soles.

Question 6

In assessing the eyes of a 4-month-old infant, a nurse shines a penlight in the infant's eyes and notices that the light reflection is not in the same location in each eye. What is the nurse's most appropriate response to this finding?

Accepted Answer

A)  Perform the cover-uncover test. 
B)  Document it as an expected finding at this age. 
C)  Document abnormal function of cranial nerves IV (trochlear) and VI (abducens). 
D)  Refer the infant to an ophthalmologist. 
A)  Perform the cover-uncover test. 
B)  Document it as an expected finding at this age. 
C)  Document abnormal function of cranial nerves IV (trochlear) and VI (abducens). 
D)  Refer the infant to an ophthalmologist.

Question 7

During a physical examination, a 12-year-old girl expresses concern to the nurse that her breasts are different sizes. Which response is most appropriate for the nurse?

Accepted Answer

A)  "This happens normally to many girls your age. Full breast development takes an average of 3 years." 
B)  "I can talk with your mother about a referral to a physician who can perform further examination and tests." 
C)  "Have you started your menstrual period yet, because breast development is irregular until menstruation begins?" 
D)  "This is called 'precocious breast development' and your breasts will become more equal just before your growth spurt starts." 
A)  "This happens normally to many girls your age. Full breast development takes an average of 3 years." 
B)  "I can talk with your mother about a referral to a physician who can perform further examination and tests." 
C)  "Have you started your menstrual period yet, because breast development is irregular until menstruation begins?" 
D)  "This is called 'precocious breast development' and your breasts will become more equal just before your growth spurt starts."

Question 8

A nurse shines the light from the ophthalmoscope into the eyes of a newborn and observes a bright, round, red-orange glow seen through both pupils. How does the nurse document this finding?

Accepted Answer

A)  An expected red reflex 
B)  Eyelid capillary hemangiomas 
C)  Bilateral conjunctivitis 
D)  Ophthalmia neonatorum 
A)  An expected red reflex 
B)  Eyelid capillary hemangiomas 
C)  Bilateral conjunctivitis 
D)  Ophthalmia neonatorum

Question 9

A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow rules when playing games. These are expected developmental achievements of a child of what age?

Accepted Answer

A)  3 years old 
B)  4 years old 
C)  5 years old 
D)  6 years old 
A)  3 years old 
B)  4 years old 
C)  5 years old 
D)  6 years old

Question 10

In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks which question?

Accepted Answer

A)  "How frequently do you eat fast food or junk food?" 
B)  "Which carbonated drinks do you drink most often?" 
C)  "Do you have any food restrictions or diet routines?" 
D)  "What are your favorite fruits and vegetables?" 
A)  "How frequently do you eat fast food or junk food?" 
B)  "Which carbonated drinks do you drink most often?" 
C)  "Do you have any food restrictions or diet routines?" 
D)  "What are your favorite fruits and vegetables?"

Question 11

The nurse places an 8-year-old boy in which position for examination of his genitalia?

Accepted Answer

A)  Supine with legs extended to either side 
B)  Lying on his left side with knees bent 
C)  Reclining with knees flexed 
D)  Standing with legs spread apart 
A)  Supine with legs extended to either side 
B)  Lying on his left side with knees bent 
C)  Reclining with knees flexed 
D)  Standing with legs spread apart

Question 12

A nurse refers which child for further assessment?

Accepted Answer

A)  A 2-year-old who has a jugular venous hum after playing 
B)  A 4-year-old who has a resting heart rate of 100 
C)  A 5-year-old who positions herself in a squat after running a few feet 
D)  A 7-year-old who has a strong femoral pulse readily detected on palpation 
A)  A 2-year-old who has a jugular venous hum after playing 
B)  A 4-year-old who has a resting heart rate of 100 
C)  A 5-year-old who positions herself in a squat after running a few feet 
D)  A 7-year-old who has a strong femoral pulse readily detected on palpation

Question 13

An adolescent patient appears reluctant to discuss sensitive issues with her parents present. What is the nurse's most appropriate intervention?

Accepted Answer

A)  Tell the patient that it is very important to be honest and specific. 
B)  Provide time when the adolescent is alone with the nurse. 
C)  Reassure the patient that anything said in the interview is considered confidential. 
D)  Ask the parents to answer the questions if the patient is not willing to answer. 
A)  Tell the patient that it is very important to be honest and specific. 
B)  Provide time when the adolescent is alone with the nurse. 
C)  Reassure the patient that anything said in the interview is considered confidential. 
D)  Ask the parents to answer the questions if the patient is not willing to answer.

Question 14

In assessing a neonate, the nurse notices that one testicle has not descended into the scrotal sac. What is the most appropriate response for the nurse as a result of this finding?

Accepted Answer

A)  Document the findings and refer this neonate for further examination for an undescended testicle. 
B)  Place a finger over the upper inguinal ring and gently push downward to try to push the testicle into the scrotum. 
C)  Use a light source to transilluminate the affected scrotal sack to determine if fluid is preventing the descent of the testicle. 
D)  Insert the fifth finger into the inguinal ring to palpate for a hernia that may have prevented the testicle from descending. 
A)  Document the findings and refer this neonate for further examination for an undescended testicle. 
B)  Place a finger over the upper inguinal ring and gently push downward to try to push the testicle into the scrotum. 
C)  Use a light source to transilluminate the affected scrotal sack to determine if fluid is preventing the descent of the testicle. 
D)  Insert the fifth finger into the inguinal ring to palpate for a hernia that may have prevented the testicle from descending.

Question 15

While examining the genitalia of a 6-year-old girl, a nurse notices which finding as expected?

Accepted Answer

A)  Clear mucoid vaginal discharge 
B)  Prepuce and clitoris are prominent. 
C)  Flat labia majora with thin labia minora 
D)  Sparse pubic hair over the inner thighs 
A)  Clear mucoid vaginal discharge 
B)  Prepuce and clitoris are prominent. 
C)  Flat labia majora with thin labia minora 
D)  Sparse pubic hair over the inner thighs

Question 16

Which statement by a mother makes the nurse assess the infant girl for cardiovascular problems?

Accepted Answer

A)  "She has gained 2 lb since our last visit." 
B)  "She naps twice a day for almost 2 hours each time." 
C)  "She gets so tired and out of breath when she takes her bottle." 
D)  "She gets fussy after I feed her and seems to have lots of gas." 
A)  "She has gained 2 lb since our last visit." 
B)  "She naps twice a day for almost 2 hours each time." 
C)  "She gets so tired and out of breath when she takes her bottle." 
D)  "She gets fussy after I feed her and seems to have lots of gas."

Question 17

Which finding rules out defects in the cornea, lens, and vitreous chamber of an infant?

Accepted Answer

A)  Bilateral red reflex 
B)  Symmetric corneal light reflex 
C)  Bilateral blink reflex 
D)  Symmetric eye movements 
A)  Bilateral red reflex 
B)  Symmetric corneal light reflex 
C)  Bilateral blink reflex 
D)  Symmetric eye movements

Question 18

After assessment of each child, the nurse determines which child needs to be referred for further evaluation?

Accepted Answer

A)  A 4-year-old child with a predominantly nasal breathing pattern 
B)  A 6-year-old child with a 1:2 anteroposterior-to-transverse-chest ratio 
C)  A 7-year-old child with a predominantly thoracic breathing pattern 
D)  A 9-year-old child with bronchovesicular breath sounds in peripheral lungs 
A)  A 4-year-old child with a predominantly nasal breathing pattern 
B)  A 6-year-old child with a 1:2 anteroposterior-to-transverse-chest ratio 
C)  A 7-year-old child with a predominantly thoracic breathing pattern 
D)  A 9-year-old child with bronchovesicular breath sounds in peripheral lungs

Question 19

Which finding during inspection of the mouth of a 1-month-old infant requires further investigation?

Accepted Answer

A)  A small loose tooth in the lower jaw 
B)  Tongue overlapping the floor of the mouth 
C)  Whitish epithelial cells on the roof of the mouth 
D)  White patches on the tongue that scrape off easily 
A)  A small loose tooth in the lower jaw 
B)  Tongue overlapping the floor of the mouth 
C)  Whitish epithelial cells on the roof of the mouth 
D)  White patches on the tongue that scrape off easily

Question 20

Which assessment technique is appropriate to measure the 8-month-old's vital signs during a well-baby check?

Accepted Answer

A)  Assess temperature using a rectal thermometer. 
B)  Observe the infant's abdomen when counting respirations. 
C)  Take the infant from the parent's arms to assess pulse. 
D)  Measure blood pressure in the leg. 
A)  Assess temperature using a rectal thermometer. 
B)  Observe the infant's abdomen when counting respirations. 
C)  Take the infant from the parent's arms to assess pulse. 
D)  Measure blood pressure in the leg.

Exam 19: Assessment of the Infant, Child, and Adolescent

During a musculoskeletal assessment of a school-age child, a nurse documents which finding as expected?

When assessing an infant, the nurse recognizes which finding requires immediate attention?

To assess the reflexes of a 5-month-old infant lying supine, the nurse turns the infant's head to the left side so that the chin is over the shoulder. What is the expected response for this reflex?

During the assessment of a newborn within hours after birth, a nurse determines which finding as abnormal?

The nurse documents which finding as normal after performing the Barlow-Ortolani maneuver on an infant?

In assessing the eyes of a 4-month-old infant, a nurse shines a penlight in the infant's eyes and notices that the light reflection is not in the same location in each eye. What is the nurse's most appropriate response to this finding?

During a physical examination, a 12-year-old girl expresses concern to the nurse that her breasts are different sizes. Which response is most appropriate for the nurse?

A nurse shines the light from the ophthalmoscope into the eyes of a newborn and observes a bright, round, red-orange glow seen through both pupils. How does the nurse document this finding?

A nurse is assessing a child who is able to dress herself, jump rope, identify colors, and follow rules when playing games. These are expected developmental achievements of a child of what age?

In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks which question?

The nurse places an 8-year-old boy in which position for examination of his genitalia?

A nurse refers which child for further assessment?

An adolescent patient appears reluctant to discuss sensitive issues with her parents present. What is the nurse's most appropriate intervention?

In assessing a neonate, the nurse notices that one testicle has not descended into the scrotal sac. What is the most appropriate response for the nurse as a result of this finding?

While examining the genitalia of a 6-year-old girl, a nurse notices which finding as expected?

Which statement by a mother makes the nurse assess the infant girl for cardiovascular problems?

Which finding rules out defects in the cornea, lens, and vitreous chamber of an infant?

After assessment of each child, the nurse determines which child needs to be referred for further evaluation?

Which finding during inspection of the mouth of a 1-month-old infant requires further investigation?

Which assessment technique is appropriate to measure the 8-month-old's vital signs during a well-baby check?

Introduction to Health Assessment

Obtaining a Health History

Techniques and Equipment for Physical Assessment

General Inspection and Measurement of Vital Signs

Cultural Assessment

Pain Assessment

Mental Health Assessment

Nutritional Assessment

Skin, Hair, and Nails

Head, Eyes, Ears, Nose, and Throat

Lungs and Respiratory System

Heart and Peripheral Vascular System

Abdomen and Gastrointestinal System

Musculoskeletal System

Neurologic System

Breasts and Axillae

Reproductive System and the Perineum

Developmental Assessment Throughout the Life Span

Assessment of the Pregnant Patient

Assessment of the Older Adult

Conducting a Head-to-Toe Examination

Documenting the Comprehensive Health Assessment

Adapting Health Assessment to the Hospitalized Patient

Filters