Question 1

A nurse assessing a 3-month-old infant suspects hydrocephalus based on which finding?

Accepted Answer

A)  Soft anterior fontanelle 
B)  Lack of head control while sitting 
C)  Increasing head circumference 
D)  Marked asymmetry of the head 
A)  Soft anterior fontanelle 
B)  Lack of head control while sitting 
C)  Increasing head circumference 
D)  Marked asymmetry of the head

Question 2

When examining lymph nodes in a 7-year-old child, the nurse records which finding as abnormal?

Accepted Answer

A)  Shotty nodes in the cervical areas 
B)  Palpable submandibular nodes 
C)  Nodes that are tender 1 week after a tetanus vaccination 
D)  Tender, fixed nodes greater than 1 cm 
A)  Shotty nodes in the cervical areas 
B)  Palpable submandibular nodes 
C)  Nodes that are tender 1 week after a tetanus vaccination 
D)  Tender, fixed nodes greater than 1 cm

Question 3

How does a nurse document a large, flat bluish capillary area on a neonate's cheek?

Accepted Answer

A)  Mongolian spot 
B)  Stork bite (telangiectasis) 
C)  Port-wine stain (nevus flammeus) 
D)  Strawberry hemangioma 
A)  Mongolian spot 
B)  Stork bite (telangiectasis) 
C)  Port-wine stain (nevus flammeus) 
D)  Strawberry hemangioma

Question 4

During a well-baby check for several 4-month-old infants, a nurse recognizes that which infant needs further assessment of an abnormal finding?

Accepted Answer

A)  The infant who is unable to sit independently 
B)  The infant whose head circumference and chest circumference are equal 
C)  The infant whose weight has doubled since birth 
D)  The infant whose length falls in the 90th percentile on growth charts 
A)  The infant who is unable to sit independently 
B)  The infant whose head circumference and chest circumference are equal 
C)  The infant whose weight has doubled since birth 
D)  The infant whose length falls in the 90th percentile on growth charts

Question 5

Which tool is most appropriate for testing the vision of a 5-year-old child?

Accepted Answer

A)  Denver II test 
B)  Snellen E chart 
C)  Allen picture cards 
D)  Snellen standard chart 
A)  Denver II test 
B)  Snellen E chart 
C)  Allen picture cards 
D)  Snellen standard chart

Question 6

In inspecting the eyes and ears of an infant, the nurse documents which finding as normal?

Accepted Answer

A)  The external ear is in direct line with the outer margin of the eyelid. 
B)  The ear lobe is within 10 degrees of alignment with the outer margin of the eyelid. 
C)  A lateral upward slant of the eyes aligns them with the helix of the ear. 
D)  The inner margin of the eye is directly aligned with the helix of the ear. 
A)  The external ear is in direct line with the outer margin of the eyelid. 
B)  The ear lobe is within 10 degrees of alignment with the outer margin of the eyelid. 
C)  A lateral upward slant of the eyes aligns them with the helix of the ear. 
D)  The inner margin of the eye is directly aligned with the helix of the ear.

Question 7

What finding does a nurse expect when assessing a 1-month-old's eyes and vision?

Accepted Answer

A)  The newborn distinguishes most colors 
B)  Tears when the newborn cries 
C)  The newborn following a bright toy or light 
D)  The newborn's blink reflex is present 
A)  The newborn distinguishes most colors 
B)  Tears when the newborn cries 
C)  The newborn following a bright toy or light 
D)  The newborn's blink reflex is present

Question 8

During assessment of an infant, the nurse notes that when the infant cries, the fontanelles bulge slightly. What is the most appropriate action for the nurse at this time?

Accepted Answer

A)  Note in the record that the child is microcephalic. 
B)  Assess the fontanelles again when the child is not crying. 
C)  Check the child for signs of malnutrition and dehydration. 
D)  Use transillumination for further assessment of the skull. 
A)  Note in the record that the child is microcephalic. 
B)  Assess the fontanelles again when the child is not crying. 
C)  Check the child for signs of malnutrition and dehydration. 
D)  Use transillumination for further assessment of the skull.

Question 9

How does a nurse respond to parents of a 5-year-old who are worried that their child has a protruding abdomen?

Accepted Answer

A)  Assesses the child to differentiate a normal "potbelly" from a hernia 
B)  Suggests that the parents administer an appropriate dose of a laxative at bedtime 
C)  Refers the parents to a nutritionist to develop an appropriate weight-loss diet for the child 
D)  Informs the parents that a protruding abdomen is always an abnormal finding in this age group 
A)  Assesses the child to differentiate a normal "potbelly" from a hernia 
B)  Suggests that the parents administer an appropriate dose of a laxative at bedtime 
C)  Refers the parents to a nutritionist to develop an appropriate weight-loss diet for the child 
D)  Informs the parents that a protruding abdomen is always an abnormal finding in this age group

Question 10

The nurse suspects respiratory distress in a newborn infant who exhibits which manifestation?

Accepted Answer

A)  Respiratory rate of 36 breaths/min 
B)  Sternal retractions 
C)  Nasal breathing 
D)  Irregular breathing pattern 
A)  Respiratory rate of 36 breaths/min 
B)  Sternal retractions 
C)  Nasal breathing 
D)  Irregular breathing pattern

Question 11

After obtaining a history from the parents and inspecting the skin, the nurse determines which child needs further evaluation?

Accepted Answer

A)  The child who has a 1-cm red spot on the back of the neck, a fever of 100° F, and clear nasal drainage. 
B)  The child who has a 2-cm slightly raised, reddened area with a sharp demarcation line on the back of the neck. 
C)  The child has a 2-cm abrasion on the right knee, a 3-cm abrasion on the left knee, and scrapes on both palms. 
D)  The child who has several flat, bluish discolorations of the skin on the abdomen and back from 2 to 6 cm. 
A)  The child who has a 1-cm red spot on the back of the neck, a fever of 100° F, and clear nasal drainage. 
B)  The child who has a 2-cm slightly raised, reddened area with a sharp demarcation line on the back of the neck. 
C)  The child has a 2-cm abrasion on the right knee, a 3-cm abrasion on the left knee, and scrapes on both palms. 
D)  The child who has several flat, bluish discolorations of the skin on the abdomen and back from 2 to 6 cm.

Question 12

Which behavior would be most indicative of hearing impairment in a 1-year-old child?

Accepted Answer

A)  Failure to respond to mother's voice 
B)  Crying when a loud noise occurs unexpectedly 
C)  Saying only single-syllable words 
D)  Disinterest in playing with musical toys 
A)  Failure to respond to mother's voice 
B)  Crying when a loud noise occurs unexpectedly 
C)  Saying only single-syllable words 
D)  Disinterest in playing with musical toys

Question 13

An American Indian mother expresses concern about an irregularly shaped, dark area over her neonate's sacrum and buttocks. What is the nurse's most appropriate response to this mother?

Accepted Answer

A)  "This area will continue to grow until the infant is 10 to 15 months old." 
B)  "This is a birth mark, which usually disappears by age 5 years." 
C)  "This skin abnormality will require follow-up care." 
D)  "This is a birth mark and they usually disappear by age 1 or 2 years." 
A)  "This area will continue to grow until the infant is 10 to 15 months old." 
B)  "This is a birth mark, which usually disappears by age 5 years." 
C)  "This skin abnormality will require follow-up care." 
D)  "This is a birth mark and they usually disappear by age 1 or 2 years."

Question 14

How does a nurse collect baseline measurements of a 6-month-old infant?

Accepted Answer

A)  Measure the chest circumference around the lower ribs. 
B)  Ask the parent how much the infant's weight has changed since birth. 
C)  Measure the head just above the ears and eyebrows. 
D)  Ask the parent to hold the infant while the nurse measures the length. 
A)  Measure the chest circumference around the lower ribs. 
B)  Ask the parent how much the infant's weight has changed since birth. 
C)  Measure the head just above the ears and eyebrows. 
D)  Ask the parent to hold the infant while the nurse measures the length.

Question 15

In performing a respiratory assessment of a 1-month-old infant, the nurse recognizes which finding as abnormal?

Accepted Answer

A)  Sneezing 
B)  Coughing 
C)  Abdominal breathing 
D)  Predominantly nose breathing 
A)  Sneezing 
B)  Coughing 
C)  Abdominal breathing 
D)  Predominantly nose breathing

Question 16

Which disorder, if any, does a nurse screen for when examining a healthy adolescent?

Accepted Answer

A)  Muscle weakness. 
B)  Limited joint range of motion. 
C)  Curvature of the spine. 
D)  No screening is needed when the adolescent is healthy. 
A)  Muscle weakness. 
B)  Limited joint range of motion. 
C)  Curvature of the spine. 
D)  No screening is needed when the adolescent is healthy.

Question 17

On assessment of an infant's abdomen, the nurse notes which finding as normal?

Accepted Answer

A)  Easily palpable spleen 
B)  Flat to slightly concave abdominal contour 
C)  Lower liver border 2 inches below the costal margin 
D)  Small protrusion between the rectus muscles when crying 
A)  Easily palpable spleen 
B)  Flat to slightly concave abdominal contour 
C)  Lower liver border 2 inches below the costal margin 
D)  Small protrusion between the rectus muscles when crying

Question 18

A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient?

Accepted Answer

A)  Asking him if the pain hurts "a little or a lot" 
B)  Asking him to rate the pain on a scale of 0 to 10 
C)  Using the visual analog scale to rate the pain 
D)  Using the Wong/Baker FACES rating scale 
A)  Asking him if the pain hurts "a little or a lot" 
B)  Asking him to rate the pain on a scale of 0 to 10 
C)  Using the visual analog scale to rate the pain 
D)  Using the Wong/Baker FACES rating scale

Question 19

What technique does a nurse use to inspect the ear canal of a 1-year-old child?

Accepted Answer

A)  Uses a light source without a speculum to minimize any trauma to the ear canal 
B)  Places the child in an upright position with the head flexed slightly downward 
C)  Applies gentle traction to the lower portion of the ear and pulls upward and laterally 
D)  Uses an assistant to hold the child's arms down and keep the child's head turned to one side 
A)  Uses a light source without a speculum to minimize any trauma to the ear canal 
B)  Places the child in an upright position with the head flexed slightly downward 
C)  Applies gentle traction to the lower portion of the ear and pulls upward and laterally 
D)  Uses an assistant to hold the child's arms down and keep the child's head turned to one side

Question 20

How does a nurse assess the head circumference of an infant?

Accepted Answer

A)  Places a ruler behind the infant's head, noting the head width 
B)  Uses a plastic headband placed around the infant's head from crown to chin 
C)  Places a measuring tape around the head above the eyebrows and occipital prominence 
D)  Uses a measuring tape to find the distance between the ears and eyes and between the eyes and occiput 
A)  Places a ruler behind the infant's head, noting the head width 
B)  Uses a plastic headband placed around the infant's head from crown to chin 
C)  Places a measuring tape around the head above the eyebrows and occipital prominence 
D)  Uses a measuring tape to find the distance between the ears and eyes and between the eyes and occiput

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

A nurse assessing a 3-month-old infant suspects hydrocephalus based on which finding?

When examining lymph nodes in a 7-year-old child, the nurse records which finding as abnormal?

How does a nurse document a large, flat bluish capillary area on a neonate's cheek?

During a well-baby check for several 4-month-old infants, a nurse recognizes that which infant needs further assessment of an abnormal finding?

Which tool is most appropriate for testing the vision of a 5-year-old child?

In inspecting the eyes and ears of an infant, the nurse documents which finding as normal?

What finding does a nurse expect when assessing a 1-month-old's eyes and vision?

During assessment of an infant, the nurse notes that when the infant cries, the fontanelles bulge slightly. What is the most appropriate action for the nurse at this time?

How does a nurse respond to parents of a 5-year-old who are worried that their child has a protruding abdomen?

The nurse suspects respiratory distress in a newborn infant who exhibits which manifestation?

After obtaining a history from the parents and inspecting the skin, the nurse determines which child needs further evaluation?

Which behavior would be most indicative of hearing impairment in a 1-year-old child?

An American Indian mother expresses concern about an irregularly shaped, dark area over her neonate's sacrum and buttocks. What is the nurse's most appropriate response to this mother?

How does a nurse collect baseline measurements of a 6-month-old infant?

In performing a respiratory assessment of a 1-month-old infant, the nurse recognizes which finding as abnormal?

Which disorder, if any, does a nurse screen for when examining a healthy adolescent?

On assessment of an infant's abdomen, the nurse notes which finding as normal?

A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient?

What technique does a nurse use to inspect the ear canal of a 1-year-old child?

How does a nurse assess the head circumference of an infant?

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