Chapter 28 The Complete Physical Assessment: Infant, Child, and Adolescent

The nursing instructor is evaluating the student nurse examining the genitals of a male neonate. Which intervention done by the student nurse needs correction? 1 Inspecting the location of the urethral meatus 2 Inspecting the strength of the infant's urine stream 3 Inspecting the glans penis by retracting the foreskin 4 Inspecting the testes by palpating the infant's scrotum

3

What assessment should the nurse include during the examination of a young child's head and face? 1 Assessing the fontanels 2 Palpating the suture lines 3 Inspecting the size of the head 4 Noting the molding of the head

3

What does the nurse do to elicit the placing reflex in an infant? 1 Let the infant's head and trunk drop back a short way 2 Place the infant supine and note the movements of the neck 3 Position the infant against the edge of the examination table 4 Pull up the infant by wrapping hands around the infant's hands

3

Which intervention should the nurse incorporate to open the eyes of a neonate for an examination? 1 Place the neonate in a supine position on the examination table 2 Ask the parent to hold the neonate while the head is tilted sideways 3 Support the head and shoulders and gently lower the neonate backward 4 Lift the neonate under the axillae, hold, and face the neonate at eye level

3

Which organ would the nurse be able to feel when doing deep palpation of the abdomen? 1 Liver 2 Spleen 3 Kidney 4 Bladder

3

While assessing a newborn, the nurse wears sterile gloves and inserts the little finger into the newborn's mouth. What would the nurse assess in the newborn by performing this intervention? 1 Scarf sign 2 Ortolani sign 3 Sucking reflex 4 Babinski reflex

3

While preparing the patient for an ophthalmic examination, the nurse places an index card on the patient's left eye. What is the reason behind this action? 1 To test the red reflex 2 To inspect the fundus 3 To conduct the cover test 4 To test for the blink reflex

3

The nurse is examining a patient's chest and thorax. Which assessments should the nurse perform in the patient in order to determine heart function? Select all that apply. 1 Auscultation of bilateral breath sounds 2 Palpation of the inguinal lymph nodes 3 Inspection of the pulsations on the precordium 4 Determination of the presence of the Ortolani sign 5 Palpation of the apical impulse with notation of the location

3, 4

Which involuntary responses does the nurse test in a newborn by using the reflex hammer? Select all that apply. 1 Red reflex 2 Moro reflex 3 Biceps reflex 4 Triceps reflex 5 Babinski reflex

3, 4

Which reflexes would the nurse test by using a reflex hammer? Select all that apply. 1 Red reflex 2 Moro reflex 3 Achilles reflex 4 Patellar reflex 5 Plantar reflex

3, 4, 5

The nurse instructs a student nurse to assess the patency of the anus in a 1-day-old neonate. How should the student nurse determine this? 1 Check for the Ortolani sign 2 Palpate the dorsalis pedis pulse 3 Palpate the inguinal lymph nodes 4 Check for the passage of meconium

4

The nurse is evaluating the neuromuscular development in a newborn. Which intervention would the nurse follow in order to test the stepping reflex in the newborn? 1 Gently place a rattle in the palms of the newborn. 2 Lay the newborn down and turn the head to one side. 3 Give a gentle stroke on the newborn's cheek with a finger. 4 Hold the newborn upright and let a foot touch the table.

4

During an assessment, the nurse suspects that the patient has a risk of peripheral vascular disease. What should the nurse palpate in order to determine the blood supply to the patient's lower extremities? 1 The apical impulse 2 The dorsalis pedis pulse 3 The inguinal lymph nodes 4 The cervical lymph nodes

2

The nurse instructs the student nurse to assess the symmetry of the facial features and positioning of the face in a newborn. When should the student nurse conduct this examination in the newborn? Select all that apply. 1 When the newborn is eating 2 When the newborn is crying 3 When the newborn is cooing 4 When the newborn is playing 5 When the newborn is sleeping

2, 5

Which vital signs does the nurse generally note while assessing a healthy neonate? Select all that apply. 1 Pain 2 Pulse 3 Respiration 4 Temperature 5 Blood pressure

2, 3, 4

While assessing an infant, the nurse pulls the infant's arm across its chest and finds that the infant's elbow does not cross the midline. What should the nurse infer from this finding? 1 Absence of the scarf sign 2 Presence of the Moro reflex 3 Absence of the Ortolani sign 4 Presence of the Babinski reflex

1

For what is the nurse testing when using the Denver II test? 1 Motor skills 2 Skin integrity 3 Hip displacement 4 Genital development

1

What intervention should the nurse incorporate in order to assess a child's eye during a cover test? 1 Cover the eye with an index card or thumb. 2 Direct a moving penlight in front of the eye. 3 Inspect the fundus with an ophthalmoscope. 4 Elicit the blink reflex with the help of a penlight.

1

What would the nurse assess in a patient's eyes by using an ophthalmoscope? 1 Red reflex 2 Blink reflex 3 Pupillary light reflex 4 Corneal light reflex

1

Which assessment should the nurse perform last during an infant examination? 1 Inspecting the tympanic membranes 2 Assessing the infant for the startle reflex 3 Examining the symmetry of the gluteal folds 4 Inspecting the trunk for the incurvation reflex

1

While doing a well-child examination of a preschooler, the student nurse initially involves the child in play and asks the child to jump and hop. Then the student nurse uses an otoscope to detect the red reflex in the child. The student nurse then asks the child to remove the underpants and performs a genital examination. Then the student nurse gives the child a pinwheel as a present. Which action of the student nurse needs correction? 1 Using an otoscope to assess the red reflex in the child 2 Presenting the pinwheel to the child after the examination 3 Initially involving the child in play and then in jumping and hopping 4 Having the child remove his or her underpants to look at the genitals

1

What assessments should the nurse include during an abdominal examination in a neonate? Select all that apply. 1 Inspecting the umbilical area 2 Assessing the umbilical stump 3 Counting the vessels in the cord 4 Palpating deeply for muscle tone 5 Auscultating the abdomen for bowel sounds

1, 2, 3, 5

What would the nurse assess while examining a patient's head, face, and neck? Select all that apply. 1 Trachea 2 Thyroid gland 3 Shoulder symmetry 4 Cervical lymph nodes 5 Trunk incurvation reflex

1, 2, 4

The nurse instructs a student nurse to assess an infant's growth by using a growth chart. Which parameters would the student nurse measure? Select all that apply. 1 Weight 2 Length 3 Blood pressure 4 Respiratory rate 5 Head circumference

1, 2, 5

Which methods would trigger the Moro reflex in an infant? Select all that apply. 1 Shaking the sides of the infant's crib 2 Startling the infant by making a loud noise 3 Tapping the infant's biceps with a reflex hammer 4 Looking at the infant's eyes with an ophthalmoscope 5 Dropping the infant's head suddenly for a short distance

1, 2, 5

After reviewing the medical history of a 3-year-old child, the nurse finds the child has appropriate growth and development. Which findings enabled the nurse to reach this conclusion? Select all that apply. 1 The child exhibits a positive red reflex. 2 The child demonstrates a positive Ortolani sign. 3 The child passed meconium 24 hours after birth. 4 The child had a Babinski reflex until 2 years of age. 5 The child had plantar grasp reflex until 13 months of age.

1, 3, 4

Which areas does the nurse assess by using a penlight during an adolescent's physical examination? Select all that apply. 1 Buccal mucosa 2 Palpebral slant 3 Nares and septum 4 Corneal light reflex 5 Tympanic membranes

1, 3, 4

What assessments should the nurse include while examining the genitalia of a female neonate? Select all that apply. 1 Inspecting the labia and clitoris 2 Checking for the passage of meconium 3 Assessing the presence of vernix caseosa 4 Assessing the strength of the urine stream 5 Inspecting the presence of a patent vagina

1, 3, 5

While assessing a child, the nurse asks the child to lie on the table in the supine position. Which examinations would the nurse be able to perform with the patient in that position? Select all that apply. 1 Cardiac examination 2 Thoracic examination 3 Abdominal examination 4 Ophthalmic examination 5 Lower extremity examination

1, 3, 5

Which of a young child's actions will help the nurse evaluate developmental milestones? Select all that apply. 1 Throwing a ball 2 Sitting and standing 3 Blowing a pinwheel 4 Standing on one foot 5 Jumping and hopping

1, 4, 5

Which actions would the nurse perform in order to detect ear disorders in a newborn? Select all that apply. 1 Complete an otoscopic examination in the newborn 2 Determine the presence of the scarf sign in the newborn 3 Assess for the presence of the red reflex in the newborn 4 Detect a palpebral slant in the newborn by using a penlight 5 Note the presence of the startle reflex in the newborn due to a loud noise

1, 5

Which parameters should the nurse assess while examining a child's upper extremities? Select all that apply. 1 Radial pulse 2 Femoral pulse 3 Stepping reflex 4 Dorsalis pedis pulse 5 Biceps and triceps reflexes

1, 5

The nurse is using a penlight to assess a patient with an ophthalmic disorder. Which parameters will the nurse test by using the penlight? Select all that apply. 1 Red reflex 2 Blink reflex 3 Palpebral slant 4 Pupillary light reflex 5 Corneal light reflex

2, 4, 5

The nurse assesses that a 3-year-old child has a staggering gait and asymmetric buttocks. Which test should the nurse expect to be completed on the child in order to diagnose the condition? 1 Scarf test 2 Ortolani test 3 Denver II test 4 Red reflex test

2

The nurse places an infant on a soft, padded surface while gently lifting the infant by supporting the head. After a while, the nurse allows the infant's head and trunk drop back a short way. What reflex is the nurse observing by doing this? 1 Red reflex 2 Moro reflex 3 Babinski reflex 4 Doll's eye reflex

2

The nursing instructor is evaluating the student nurse as the student nurse assesses the tonic neck reflex in an infant. Which of the student nurse's interventions indicates effective learning? 1 Turning the infant's head and observing the eye movements during the test 2 Placing the infant in a supine position on an examination table during the test 3 Holding the infant's head and shoulders off the examination table during the test 4 Holding the infant in an upright position and placing the infant's foot on the table during the test

2

The student nurse is examining the lower limbs of an adolescent patient who has sustained severe injuries. Which of the student nurse's actions should be corrected by the supervising nurse? 1 Placing the patient in a supine position 2 Placing the patient in an upright position 3 Providing a towel as a drape for the patient 4 Having the patient lower pants under the drape

2

What should the nurse assess as a young child plays with toys in the examination room? 1 Alignment of the legs 2 Gross and fine motor skills 3 Size and shape of the head 4 Parent and child interaction

2

Which assessment helps the nurse assess an infant's upper extremities? 1 Eliciting patellar reflexes 2 Evaluating for the scarf sign 3 Assessing for the Ortolani sign 4 Testing the reflex of the biceps

2

Which parameters should the nurse assess while examining a patient's abdomen? Select all that apply. 1 Apical pulse 2 Bowel sounds 3 Femoral pulse 4 Cardiac murmurs 5 Dorsalis pedis pulse

2, 3

What does the nurse assess when lightly palpating an infant's abdomen? Select all that apply. 1 Kidneys 2 Spleen tip 3 Muscle tone 4 Urinary bladder 5 Presence of a mass

2, 3, 4

The nurse is performing an otoscopic examination in a preschooler. The child refuses to sit still on the chair and does not cooperate with the nurse during the examination. Which intervention should the nurse use to gain the child's cooperation? 1 Restrain the child to do the examination 2 Instruct the child in a firm voice to sit still 3 Ask the parents to hold the child very firmly 4 Encourage the child to handle the otoscope

4

The nurse observes a student nurse who is examining the mouth, throat, nose, and eyes of a young child. Which intervention by the student nurse needs correction? 1 Using a penlight to determine the cardinal positions of gaze 2 Using an ophthalmoscope to verify the red reflex in the child 3 Using a penlight to inspect for any foreign bodies in the nose 4 Using a tongue blade initially to examine the mouth and the throat

4

What is the nurse assessing in a newborn by using the Apgar scoring system five minutes after birth? 1 Hearing ability in the newborn 2 Visual disorders in the newborn 3 Neuromuscular function in the newborn 4 Response of the newborn to extrauterine life

4

While completing a neuromuscular assessment in a newborn, the nurse turns the newborn's head from one side to the other. Which reflex can the nurse test in the newborn with this intervention? 1 Grasp reflex 2 Rooting reflex 3 Babinski reflex 4 Doll's eye reflex

4

While examining a newborn, the nurse inspects the trunk incurvation reflex. What body part is the nurse assessing by doing this? 1 Lower limbs 2 Upper limbs 3 Genital organs 4 Spinal column

4

What would the nurse assess in a patient by using an otoscope? Select all that apply. 1 Presence of the red reflex 2 Absence of the Ortolani sign 3 Patency of both of the nostrils 4 Condition of the auditory canal 5 Intactness of the tympanic membrane

4, 5