Question 1

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

A)   Vesicular
B)   Bronchial
C)   Adventitious
D)   Bronchovesicular A

Question 2

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Accepted Answer

A)   S1, S2
B)   S3, S4
C)   Murmur
D)   Physiological splitting C

Question 3

What is the appropriate placement for a tongue blade to assess the mouth and throat?

Accepted Answer

A)   Centre back area of tongue
B)   Side of the tongue
C)   Against the soft palate
D)   On the lower jaw B

Question 4

Which data is included in a health history?

Accepted Answer

A)   Review of systems
B)   Physical assessment
C)   Vital sign assessment
D)   Growth measurements

Question 5

How should the nurse assess a child's capillary filling time?

Accepted Answer

A)   Inspect the chest.
B)   Auscultate the heart.
C)   Palpate the apical pulse.
D)   Palpate the skin to produce a slight blanching.

Question 6

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 7

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones,such as the age when he started walking without assistance.How should milestones be considered?

Accepted Answer

A)   They are unnecessary because the child is age 3 years.
B)   They are an important part of the family history.
C)   They are an important part of the child's past growth and development.
D)   They are an important part of the child's review of systems.

Question 8

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.What is the priority action?

Accepted Answer

A)   Refer for immediate medical evaluation.
B)   Continue assessment to determine cause of neck pain.
C)   Ask parent when neck was injured.
D)   Record "head lag" on assessment record and continue assessment of child.

Question 9

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

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

The nurse is seeing an adolescent boy and his parents in the clinic for the first time.What should the nurse do first?

Accepted Answer

A)   Introduce him- or herself.
B)   Make the family comfortable.
C)   Explain the purpose of the interview.
D)   Give an assurance of privacy.

Question 11

The nurse is interviewing the mother of an infant.She reports,"I had a difficult delivery,and my baby was born prematurely." This information should be recorded under which heading?

Accepted Answer

A)   Birth history
B)   Present illness
C)   Chief complaint
D)   Review of systems

Question 12

During an examination of a toddler's extremities,the nurse notes that the child is bowlegged.How should the nurse document this finding?

Accepted Answer

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

Question 13

A nurse is taking the sexual history of an adolescent girl.Which is the best way to determine whether she is sexually active?

Accepted Answer

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

Question 14

A nurse knows that the patient is experiencing information overload when she observes that the patient is doing one of the following?

Accepted Answer

A)   Maintains eye contact
B)   Plays with hair
C)   Has fixed, narrowed eyes
D)   Remains focused on the topic of discussion

Question 15

According to the WHO Growth Reference Charts,which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

Accepted Answer

A)   10th percentile
B)   25th percentile
C)   90th percentile
D)   95th percentile

Question 16

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup.Which criteria should the nurse use to determine the appropriate-size blood pressure cuff?

Accepted Answer

A)   The cuff is labelled "toddler."
B)   The cuff bladder width is approximately 80% of the circumference of the upper arm.
C)   The cuff bladder length covers 80% to 100% of the circumference of the upper arm.
D)   The cuff bladder covers 50% to 66% of the length of the upper arm.

Question 17

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

Accepted Answer

A)   Height
B)   Weight
C)   Skin-fold thickness
D)   Upper arm circumference

Question 18

The nurse has a 2-year-old boy sit in the "tailor" position during palpation for the testes.What is the rationale for this position?

Accepted Answer

A)   It prevents cremasteric reflex.
B)   Undescended testes can be palpated.
C)   This tests the child for an inguinal hernia.
D)   The child does not yet have a need for privacy.

Question 19

Where in the health history should the nurse describe all the details related to the chief complaint?

Accepted Answer

A)   Past history
B)   Chief complaint
C)   Present illness
D)   Review of systems

Question 20

What is an important consideration for the nurse who is communicating with a very young child?

Accepted Answer

A)   Speak loudly, clearly, and directly.
B)   Use transition objects, such as a doll.
C)   Disguise one's own feelings, attitudes, and anxiety.
D)   Initiate contact with the child when his or her parent is not present.

Exam 34: Communication, history, physical, and Developmental Assessment