263 chapter 32
3) A nurse working in the nursery notes that a newborn is having frequent episodes of apnea lasting 10 to 15 seconds without any changes in color or decreases in heart rate. Which intervention would be the most appropriate? 1. Continue to observe and call the healthcare provider if the apnea lasts longer than 20 seconds. 2. Suction the mouth and nares. 3. Call the healthcare provider immediately. 4. Turn the newborn to the right side.
Answer: 1 Explanation: 1. Apnea lasting less than 20 seconds is a normal finding in newborns as long as there is no associated cyanosis or bradycardia, so continued observation is the most appropriate intervention. 2. There is no indication that suctioning is needed. 3. It is unnecessary to inform the healthcare provider, as apnea lasting 10 to 15 seconds is normal in a newborn. 4. Turning the baby is not necessary, as apnea lasting 10 to 15 seconds in a newborn is normal.
2) The nurse is taking a health history from the family of a 3-year-old child. Which statement or question by the nurse would be most likely to establish rapport and elicit an accurate response from the family? 1. "Tell me about the concerns that brought you to the clinic today." 2. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 3. "Hello, I would like to talk with you and get some information about you and your child." 4. "You will need to fill out these forms; make sure that the information is as complete as possible."
Answer: 1 Explanation: 1. Asking the parents to talk about their concerns is an open-ended question and one that is more likely to establish rapport and an understanding of the parents' perceptions. 2. Asking about a number of items at once might be confusing to the family. 3. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed will be even more effective at establishing rapport and also getting more accurate, pertinent information. 4. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified by the nurse directing the interview.
1) During the newborn examination, the nurse assesses for signs of developmental dysplasia of the hip. Which finding would strongly suggest this disorder? 1. Asymmetric thigh and gluteal folds 2. A positive Babinski reflex 3. A negative Moro reflex 4. Flat soles with prominent fat pads
Answer: 1 Explanation: 1. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip and require follow-up with an ultrasound. 2. A positive Babinski reflex is a normal finding in a newborn. 3. The Moro reflex involves both arms and legs. A positive Moro reflex is normal in the newborn. The absence of the Moro can indicate a brain or tissue injury. 4.Flat soles are normal in newborns.
15) During a routine physical assessment for a 9-month-old client, the nurse notes swelling in the ankles. The nurse presses against the ankle bone for 5 seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation. Which system requires a more in-depth assessment based on these data? 1. Renal system 2. Musculoskeletal system 3. Respiratory system 4. Integumentary system
Answer: 1 Explanation: 1. Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney disorder, so the renal system is affected. The renal system would be suspected before the respiratory, musculoskeletal, or integumentary system. 2. Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney disorder, so the renal system is affected. The renal system would be suspected before the respiratory, musculoskeletal, or integumentary system. 3. Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney disorder, so the renal system is affected. The renal system would be suspected before the respiratory, musculoskeletal, or integumentary system. 4. Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney disorder, so the renal system is affected. The renal system would be suspected before the respiratory, musculoskeletal, or integumentary system.
14) While assessing a 10-month-old infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would require more in-depth assessment based on this finding? 1. Hepatic 2. Cardiac 3. Genitourinary 4. Respiratory
Answer: 1 Explanation: 1. This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver or hepatic system. 2. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. 3. Tenting of the skin and dry mucous membranes could be signs of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. 4. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.
8) While assessing a school-age child, the nurse notices a regular-irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration. Which nursing action is appropriate based on these data? 1. Record the finding as normal. 2. Notify the healthcare provider. 3. Schedule an electrocardiogram (ECG) immediately. 4.Ask the mother if a murmur has been detected before
Answer: 1 Explanation: 1. This is sinus arrhythmia and is a normal finding in children but not in adults. 2. This is a normal finding. It should be recorded, not reported. 3. Nurses do not order tests, including ECGs. 4.There is no evidence of a murmur in the assessment data provided. This is a normal
10) Which would the nurse consider as normal during a newborn assessment? Select all that apply. 1. Swelling over the occiput that crosses suture lines 2. Tiny white papules located primarily on the nose and chin 3. Tiny red macules and pustules that come and go, primarily on the trunk and extremities 4. When the Moro reflex is elicited, the right arm extends and returns to the body. The left arm remains resting against the chest. 5. Greenish discoloration of skin over the entire body that is not removed by the initial bath
Answer: 1, 2, 3 Explanation: 1. By crossing suture lines, this finding indicates it is caput succedaneum, a normal finding after vaginal delivery. No further evaluation or treatment is needed. 2. This is a description of milia, a normal finding. No further care is required. 3. This is a description of erythema toxicum, a normal newborn finding that requires no further treatment. 4. This Moro reflex is incomplete. Further evaluation is necessary to determine if there has been injury to the right arm and/or shoulder. 5. This is a description of a meconium-stained newborn. The passage of meconium has occurred at a more distant time, leading to the staining. The child will need to be evaluated for meconium aspiration.
17) Which assessment strategies are appropriate when assessing a family of Asian descent, who speak fluent English, during a scheduled health maintenance appointment for a toddler-age child? Select all that apply. 1. Using open-ended questions 2. Phrasing questions in a neutral manner 3. Avoiding prolonged eye contact 4. Asking all questions directly to the interpreter 5.Asking several questions for time management purposes
Answer: 1, 2, 3 Explanation: 1. Open-ended questions should be used during all health history interviews, if possible. It is especially important with families of Asian descent who tend to answer with "yes" or anticipate the answer the nurse wants to hear. 2. The nurse phrases questions in a neutral manner in order to decrease the risk of the family anticipating the answer that the nurse wants to hear, which often occurs with families of Asian descent. 3. Direct or prolonged eye contact is often seen as a sign of disrespect when assessing a family of Asian descent. 4. While the family is of Asian descent, the family speaks fluent English; therefore, there is no need for an interpreter unless the family requests this service. If an interpreter is used, the nurse would direct the questions to the family, not the interpreter. 5.The nurse will ask questions one at a time and avoid asking several questions at once
16) Which questions will the nurse include in the health history for an infant when assessing the birth history? Select all that apply. 1. "When did you first receive prenatal care when you learned you were pregnant?" 2. "Where was your baby born?" 3. "Was your baby born vaginally or by cesarean birth?" 4. "Is your baby experiencing vomiting after bottle feedings?" 5. "Does your baby take any medications on a regular basis?"
Answer: 1, 2, 3 Explanation: 1. The nurse asks questions related to prenatal care when assessing the infant's birth history during the health history interview. 2. The nurse asks questions to determine a description of the birth when assessing the infant's birth history during the health history interview. 3. The nurse asks questions about the type of birth when assessing the infant's birth history during the health history interview. 4. The nurse would ask questions regarding vomiting after bottle feeding when assessing the history of the present illness during the health history interview. 5. The nurse would ask questions regarding medication use when assessing the history of the present illness during the health history interview.
20) Which techniques would the nurse use when assessing a preschool-age child? Select all that apply. 1. Asking the child to sit on the examination table 2. Having the child undress for the examination leaving on the undergarments. 3. Asking the child when he or she would like to have head, eyes, and ears assessed 4. Asking direct questions to the child 5.Having the parent of the child leave the room for the duration of the exam
Answer: 1, 2, 3, 4 Explanation: 1. It is appropriate for the nurse to assess the preschool-age child on the examination table. 2. It is appropriate for the nurse to ask the preschool-age child to remove all clothing except for the undergarments. 3. It is appropriate to give the prechool-age child a choice regarding when the nurse will assess a certain system. 4. It is appropriate to ask the preschool-age child questions directly. 5. While some preschool-age children will feel comfortable being assessed without the presence of a parent, it is not appropriate to have the parent leave the room for the duration of the assessment.
19) Which statements are true in regard to the physical assessment the nurse conducts for an infant and a toddler? Select all that apply. 1. An infant client will have all clothing removed during the weight assessment. 2. A toddler client's assessment will include a length assessment instead of a height assessment. 3. An infant client will have a blood pressure assessment at each visit. 4. It is inappropriate to ask the toddler-age client if he or she can perform certain tasks. 5. It is appropriate to allow the toddler-age client to play with equipment prior to use.
Answer: 1, 4 Explanation: 1. An infant client will have all clothing removed during the weight assessment. 2. The toddler-age client will be assessed for weight and height. Length is used when assessing an infant client. 3. Infant clients do not routinely have their blood pressure assessed. This will become a part of the assessment process at the age of 3 years. 4. The nurse would not ask the toddler-age client if they can perform certain tasks, as the answer will typically be "no." 5. Toddlers should not be allowed to play with equipment during the assessment process. It is appropriate to demonstrate the use of the instruments on the parent when assessing a toddler-age client.
9) While assessing the blood pressure of a school-age child, the nurse notes the following: Systolic sound is heard at 98, but the sound continues until it reaches 0. There is a distinct sound softening at 48. How should the nurse record this finding? 1. 98/48 2. 98/48/0 3. 98/0 4. 48/0
Answer: 2 Explanation: 1. This is not the correct documentation. Korotkoff sounds were heard down to 0 mmHg. 2. This documentation correctly records the nurse's findings. 3. This is not the correct documentation, as it does not include the qualitative change at 48. 4. This reading eliminates the systolic sound.
7) Which action by the nurse is appropriate when selecting a cuff to accurately assess blood pressure (BP) on a child? 1. Select based on the label—infant, child, adult. 2. Select based on a bladder that covers two thirds of the upper arm and wraps around at least 80% of the arm circumference. 3. Select based on availability. 4. Select based on a bladder that covers one fourth of the arm circumference and 50% of the upper arm.
Answer: 2 Explanation: 1. While the label may provide guidance for selecting a BP cuff, this action is not appropriate. 2. This is an accurate measurement to determine cuff size. 3. BP readings will be inaccurately high or low based on whether the cuff is too large or too small. 4.This is incorrect and will result in a cuff that is too small
13) Which question from the nurse during a health history and physical assessment for the school-age child would best determine cognitive development? 1. "What grade are you in?" 2. "What is your least favorite class?" 3. "What books have you read lately?" 4."What classes are you taking, and what are your grades in them
Answer: 4 Explanation: 1. Grade level is also a good indication of cognitive development, but there could be many different reasons that a child has been held back in school that are not related to cognitive development. 2. Determining classes the child does not enjoy would be helpful, but not the best determinant of poor cognitive development. 3. Many children have not been encouraged to read books, and while the types of books read would be a good indication of cognitive development, lack of interest in reading would not necessarily indicate poor cognitive development. 4. Asking about what kind of classes the child is taking and the grades that the child is receiving in those classes would give the nurse an indication of how the child is developing cognitively.
18) Which actions by the nurse are appropriate to enhance cooperation when assessing a 10-month-old infant? Select all that apply. 1. Placing the infant on the examination table 2. Using toys to distract the infant 3. Touching the infant's feet before moving on to the trunk 4. Keeping the infant's clothing on during the process 5. Observing the infant's interaction with the mother while she is holding the baby
Answer: 2, 3, 5 Explanation: 1. The infant should be allowed to remain in the lap of the mother during as much of the examination as possible in order to enhance cooperation. 2. It is appropriate for the nurse to use toys to enhance cooperation during the infant assessment. 3. The nurse should first touch the infant's feet before moving onto the trunk to enhance cooperation during the assessment process. 4. It is not necessary to keep the infant clothed during the assessment process. The nurse should, however, ensure the room is warm enough for the removal of clothing during the assessment process. 5. It is appropriate for the nurse to observe the interaction between infant and mother while the mother holds the infant during the assessment process.
11) The nurse is conducting an admission assessment for a newborn client. Which physical findings suggest the newborn is preterm? Select all that apply. 1. The ear pinna quickly returns to original position after being bent manually. 2. The infant's resting position is tightly flexed. 3. Labia are widely separated with clitoris prominent. 4. Breast area is barely perceptible with flat areola, no bud. 5.Sole creases do not extend the length of the foot
Answer: 3, 4, 5 Explanation: 1. This finding is associated with fetal maturity. 2. This finding is associated with fetal maturity. A preterm baby will rest with arms and legs extended. 3. The labia cover the perineal area, including the clitoris for a term newborn. 4. This is an indication of immaturity associated with the prematurity. 5. This is an indication of prematurity.
12) The nurse is conducting a health history for the family of a 3-year-old child. Which statements or questions by the nurse would establish rapport and elicit an accurate response from the family? Select all that apply. 1. "Hello, I would like to talk with you and get some information on you and your child." 2. "Does any member of your family have a history of asthma, heart disease, or diabetes?" 3. "Tell me about the concerns that brought you to the clinic today." 4. "You will need to fill out these forms; make sure that the information is as complete as possible." 5. Asking the child, "What is your doll's name?"
Answer: 3, 5 Explanation: 1. Introducing self before asking the parents for information is likely to establish rapport, but it does not give the nurse an understanding of the parents' perceptions. 2. Beginning with a question about family history of diseases does not establish rapport. 3. Asking the parents to talk about their concerns is an open-ended question, and one that will establish rapport and give the nurse an understanding of the parents' perceptions. 4. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified by the nurse directing the interview. 5. Including the child in the health history process by asking the name of the doll is aquestion from the nurse that establishes rapport.
6) The nurse prepares to conduct a quick evaluation of a 1-month-old infant's hearing. Which action will provide the best information? 1. Examining the child's ear canal with an otoscope 2. Using a vibrating tuning fork placed against the child's skull 3. Using tympanometry to assess the child's hearing 4. Using a noisemaker to evaluate the child's response
Answer: 4 Explanation: 1. Inspection of the ear canal and membrane will not provide any information on the infant's hearing ability. 2. In a school-age child, this will test bone conduction, but it is not appropriate for an infant. 3. Tympanometry is a tool to evaluate the movement of the tympanic membrane. Although related to sound transmission, it is not the best response. 4. This is a quick, simple evaluation of the child's ability to hear sounds. The child's response can be a stopping of activity, widening of the eyes, or turning toward the sound.
4) The nurse is completing a physical examination of a 4-year-old girl. Which is the best position to place the child in to assess the genitalia? 1. Supine, with legs at a 50-degree angle 2. Right side-lying 3. In prone position, with knees drawn up under the body 4.Frog-legged position
Answer: 4 Explanation: 1. The child will not tolerate the legs at a 50-degree angle for long. 2. There is no reason for a side-lying position, and the child will not tolerate holding the top leg up for long. 3. Prone with knees drawn up will allow assessment of the anus, but it will not allow for visualization of the vaginal area. 4. Having the child lie supine, flexing her knees and pulling them up to a frog-legged position, allows for accurate assessment of the genitalia and is well tolerated by the majority of children.
5) Which is the correct order for the nurse to conduct a physical assessment for a toddler-age client? Place in order from first assessment to last assessment. 1. Auscultation of chest 2. Examination of eyes, ears, and throat 3. Palpation of abdomen 4.General appearance
Answer: 4, 1, 3, 2 Explanation: 1. Auscultation usually is less threatening to the toddler than is palpation, especially if the nurse first demonstrates using the stethoscope on a parent or a toy. 2. The most uncomfortable, most invasive examination for the toddler is most likely to be the examination of the eyes, ears, and throat; therefore, this assessment should be performed last. 3. Palpation can be more threatening than is observing or listening, so it should be completed after both. 4.The nurse will begin the assessment by looking at the child. This can be done while the mother is holding the child and the nurse is talking to the mother. This environment will be neutral for the child and will not cause anxiety
