Question 1

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

Accepted Answer

A)  Delayed sexual development
B)  Edema
C)  Pruritus
D)  Jaundice
E)  Paresthesia A,C,D

Question 2

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones such as the age of walking without assistance.This should be considered because these milestones are:

Accepted Answer

A)  Unnecessary information because the child is age 3 years.
B)  An important part of the family history.
C)  An important part of the child's past growth and development.
D)  An important part of the child's review of systems. C

Question 3

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

A)  Elicit one answer at a time.
B)  Interrupt the interpreter if the response from the family is lengthy.
C)  Comments to the interpreter about the family should be made in English.
D)  Arrange for the family to speak with the same interpreter, if possible.
E)  Introduce the interpreter to the family. A,D,E

Question 4

Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

-Step 4

Accepted Answer

A)  Auscultation
B)  Palpation
C)  Inspection
D)  Percussion

Question 5

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

Accepted Answer

A)  Abnormal and requires further investigation.
B)  Abnormal unless it occurs in conjunction with knock-knee.
C)  Normal if the condition is unilateral or asymmetric.
D)  Normal because the lower back and leg muscles are not yet well developed.

Question 6

The nurse should expect the anterior fontanel to close at age:

Accepted Answer

A)  2 months
B)  2 to 4 months
C)  6 to 8 months
D)  12 to 18 months

Question 7

During a funduscopic examination of a school-age child,the nurse notes a brilliant,uniform red reflex in both eyes.The nurse should recognize that this is:

Accepted Answer

A)  A normal finding.
B)  An abnormal finding; the child needs referral to an ophthalmologist.
C)  A sign of a possible visual defect; the child needs vision screening.
D)  A sign of small hemorrhages, which usually resolve spontaneously.

Question 8

The nurse is taking a health history on an adolescent.What best describes how the chief complaint should be determined?

Accepted Answer

A)  Ask for a detailed listing of symptoms.
B)  Ask the adolescent, "Why did you come here today?"
C)  Use what the adolescent says to determine, in correct medical terminology, what the problem is.
D)  Interview the parent away from the adolescent to determine the chief complaint.

Question 9

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

Accepted Answer

A)  Some form of cancer.
B)  Local scalp infection common in children.
C)  Infection or inflammation distal to the site.
D)  Infection or inflammation close to the site.

Question 10

Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

-Step 2

Accepted Answer

A)  Auscultation
B)  Palpation
C)  Inspection
D)  Percussion

Question 11

The nurse must assess 10-month-old infant.The infant is sitting on the father's lap and appears to be afraid of the nurse and of what may happen next.Which initial action by the nurse would be most appropriate?

Accepted Answer

A)  Initiate a game of peek-a-boo.
B)  Ask the father to place the infant on the examination table.
C)  Undress the infant while he is still sitting on his father's lap.
D)  Talk softly to the infant while taking him from his father.

Question 12

With the National Center for Health Statistics (NCHS)criteria,which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

Accepted Answer

A)  10th percentile
B)  9th percentile
C)  85th percentile
D)  95th percentile

Question 13

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

Accepted Answer

A)  1 month
B)  6 to 9 months
C)  1 to 2 years
D)  2.5 to 3 years

Question 14

The nurse is taking a sexual history on an adolescent girl.The best way to determine whether she is sexually active is to:

Accepted Answer

A)  Ask her, "Are you sexually active?"
B)  Ask her, "Are you having sex with anyone?"
C)  Ask her, "Are you having sex with a boyfriend?"
D)  Ask both the girl and her parent if she is sexually active.

Question 15

The nurse must assess a child's capillary filling time.This can be accomplished by:

Accepted Answer

A)  Inspecting the chest.
B)  Auscultating the heart.
C)  Palpating the apical pulse.
D)  Palpating the skin to produce a slight blanching.

Question 16

Which tool measures body fat most accurately?

Accepted Answer

A)  Stadiometer
B)  Calipers
C)  Cloth tape measure
D)  Paper or metal tape measure

Question 17

The nurse is using the NCHS growth chart for an African-American child.The nurse should consider that:

Accepted Answer

A)  This growth chart should not be used.
B)  Growth patterns of African-American children are the same as for all other ethnic groups.
C)  A correction factor is necessary when the NCHS growth chart is used for non-Caucasian ethnic groups.
D)  The NCHS charts are accurate for U.S. African-American children.

Question 18

Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last.

-Step 3

Accepted Answer

A)  Auscultation
B)  Palpation
C)  Inspection
D)  Percussion

Question 19

What term is used to describe breath sounds that are produced as air passes through narrowed passageways?

Accepted Answer

A)  Rubs
B)  Rattles
C)  Wheezes
D)  Crackles

Question 20

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change.The nurse decides to do a simple magic trick using gauze.This should be interpreted as:

Accepted Answer

A)  Inappropriate, because of child's age.
B)  A way to establish rapport.
C)  Too distracting, when cooperation is important.
D)  Acceptable, if there is adequate time.

Exam 29: Communication, history, and Physical Assessment

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

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones such as the age of walking without assistance.This should be considered because these milestones are:

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) ?

Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last. -Step 4

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

The nurse should expect the anterior fontanel to close at age:

During a funduscopic examination of a school-age child,the nurse notes a brilliant,uniform red reflex in both eyes.The nurse should recognize that this is:

The nurse is taking a health history on an adolescent.What best describes how the chief complaint should be determined?

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

Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last. -Step 2

The nurse must assess 10-month-old infant.The infant is sitting on the father's lap and appears to be afraid of the nurse and of what may happen next.Which initial action by the nurse would be most appropriate?

With the National Center for Health Statistics (NCHS) criteria,which body mass index (BMI) -for-age percentile indicates a risk for being overweight?

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

The nurse is taking a sexual history on an adolescent girl.The best way to determine whether she is sexually active is to:

The nurse must assess a child's capillary filling time.This can be accomplished by:

Which tool measures body fat most accurately?

The nurse is using the NCHS growth chart for an African-American child.The nurse should consider that:

Match the assessment examination techniques used when performing an abdominal assessment with the sequential step numbers. Begin with the first technique and end with the last. -Step 3

What term is used to describe breath sounds that are produced as air passes through narrowed passageways?

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change.The nurse decides to do a simple magic trick using gauze.This should be interpreted as: