Chapter 29: Communication, History, & Physical Assessment
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. a. Auscultation c. Inspection b. Palpation d. Percussion 47. Step 1 48. Step 2 49. Step 3 50. Step 4
47. C 48. A 49. D 50. B
1. The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce himself or herself. b. Make the family comfortable. c. Explain the purpose of the interview. d. Give an assurance of privacy.
A
12. 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? a. Birth history b. Present illness c. Chief complaint d. Review of systems
A
25. The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. The most appropriate action is to: a. Refer for immediate medical evaluation. b. Continue the assessment to determine the cause of neck pain. c. Ask the parent when the childs neck was injured. d. Record head lag on the assessment record and continue the assessment of the child.
A
27. 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: 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.
A
32. 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? a. Vesicular b. Bronchial c. Adventitious d. Bronchovesicular
A
36. The nurse has a 2-year-old boy sit in tailor position during palpation for the testes. The rationale for this position is that: 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.
A
40. The nurse must assess 10-month-old infant. The infant is sitting on the fathers 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? 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 fathers lap. d. Talk softly to the infant while taking him from his father.
A
5. When introducing hospital equipment to a preschooler who seems afraid, the nurses approach should be based on which principle? a. The child may think the equipment is alive. b. The child is too young to understand what the equipment does. c. Explaining the equipment will only increase the childs fear. d. One brief explanation is enough to reduce the childs fear.
A
45. 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)? a. Delayed sexual development b. Edema c. Pruritus d. Jaundice e. Paresthesia
A, C, D
43. Which data would be included in a health history (Select all that apply)? a. Review of systems b. Physical assessment c. Sexual history d. Growth measurements e. Nutritional assessment f. Family medical history
A, C, E, F
46. 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)? 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
10. The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? 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.
B
14. The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: 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.
B
20. Which tool measures body fat most accurately? a. Stadiometer b. Calipers c. Cloth tape measure d. Paper or metal tape measure
B
22. The earliest age at which a satisfactory radial pulse can be taken in children is: a. 1 year b. 2 years c. 3 years d. 6 years
B
28. Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? a. 1 month b. 3 to 4 months c. 6 to 8 months d. 12 months
B
31. The appropriate placement of a tongue blade for assessment of the mouth and throat is the: a. The center back area of the tongue. b. The side of the tongue. c. Against the soft palate. d. On the lower jaw.
B
38. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the finger-to-nose test. The nurse is testing for: a. Deep tendon reflexes. b. Cerebellar function. c. Sensory discrimination. d. Ability to follow directions.
B
39. 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: a. Inappropriate, because of childs age. b. A way to establish rapport. c. Too distracting, when cooperation is important. d. Acceptable, if there is adequate time.
B
4. What is an important consideration for the nurse who is communicating with a very young child? a. Speak loudly, clearly, and directly. b. Use transition objects such as a doll. c. Disguise own feelings, attitudes, and anxiety. d. Initiate contact with the child when the parent is not present.
B
8. When the nurse interviews an adolescent, it is especially important to: a. Focus the discussion on the peer group. b. Allow an opportunity to express feelings. c. Emphasize that confidentiality will always be maintained. d. Use the same type of language as the adolescent.
B
42. 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 in determining the appropriate-size blood pressure cuff (Select all that apply)? a. The cuff is labeled toddler. b. The cuff bladder width is approximately 40% 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.
B, C
44. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis (Select all that apply)? a. Complaints of a sore back b. Asymmetry of the shoulders c. An uneven hemline d. Inability to bend at the waist e. Unequal waist angles
B, C, E
11. Where in the health history should the nurse describe all details related to the chief complaint? a. Past history b. Chief complaint c. Present illness d. Review of systems
C
13. 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. Unnecessary information because the child is age 3 years. b. An important part of the family history. c. An important part of the childs past growth and development. d. An important part of the childs review of systems.
C
15. When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: a. Indicates that they live in poverty. b. Is lacking in protein. c. May provide sufficient amino acids. d. Should be enriched with meat and milk.
C
17. An appropriate approach to performing a physical assessment on a toddler is to: a. Always proceed in a head-to-toe direction. b. Perform traumatic procedures first. c. Use minimal physical contact initially. d. Demonstrate use of equipment.
C
18. With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)for-age percentile indicates a risk for being overweight? a. 10th percentile b. 9th percentile c. 85th percentile d. 95th percentile
C
2. Which action is most likely to encourage parents to talk about their feelings related to their childs illness? a. Be sympathetic. b. Use direct questions. c. Use open-ended questions. d. Avoid periods of silence.
C
21. By what age do the head and chest circumferences generally become equal? a. 1 month b. 6 to 9 months c. 1 to 2 years d. 2.5 to 3 years
C
23. Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles
C
3. What is the single most important factor to consider when communicating with children? a. The childs physical condition b. The presence or absence of the childs parent c. The childs developmental level d. The childs nonverbal behaviors.
C
30. The nurse is testing an infants visual acuity. By what age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months d. 6 months
C
33. What term is used to describe breath sounds that are produced as air passes through narrowed passageways? a. Rubs b. Rattles c. Wheezes d. Crackles
C
35. What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? a. S1, S2 b. S3, S4 c. Murmur d. Physiologic splitting
C
41. During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurses most appropriate action? a. Teach the parents appropriate exercises. b. Recheck head control at the next visit. c. Refer the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open.
C
6. Which age group is most concerned with body integrity? a. Toddler b. Preschooler c. School-age child d. Adolescent
C
7. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: a. Ask her why she wants to know. b. Determine why she is so anxious. c. Explain in simple terms how it works. d. Tell her she will see how it works as it is used.
C
16. Which parameter correlates best with measurements of the bodys total protein stores? a. Height b. Weight c. Skin-fold thickness d. Upper arm circumference
D
19. The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that: 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.
D
24. When palpating the childs cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: 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.
D
26. The nurse should expect the anterior fontanel to close at age: a. 2 months b. 2 to 4 months c. 6 to 8 months d. 12 to 18 months
D
29. The most frequently used test for measuring visual acuity is the: a. Denver Eye Screening test. b. Allen picture card test. c. Ishihara vision test. d. Snellen letter chart.
D
34. The nurse must assess a childs capillary filling time. This can be accomplished by: a. Inspecting the chest. b. Auscultating the heart. c. Palpating the apical pulse. d. Palpating the skin to produce a slight blanching.
D
37. During examination of a toddlers extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: 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.
D
9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique may be most helpful? a. Suggest that the child keep a diary. b. Suggest that the parent read fairy tales to the child. c. Ask the parent whether the child is always uncommunicative. d. Ask the child to draw a picture.
D
