Exam 1: Chapter 4

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 self. B. Make family comfortable. C. Explain purpose of interview. D. Give assurance of privacy.

A The first thing that nurses should do is to introduce themselves to the patient and family.

A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child? A. Up and back B. Down and back C. Straight back D. Straight up

A With older children, usually those older than 3 years of age, the canal curves downward and forward.

Which of the following 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 The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history.

A nurse is performing an assessment on a school-age child. Which findings suggest the child is getting an excess of vitamin A? (Select all that apply.) A. Delayed sexual development B. Edema C. Pruritus D. Jaundice E. Paresthesia

A,C,D

Which approach would be best to use to ensure a positive response from a toddler? A. Assume an eye-level position and talk quietly. B. Call the toddler's name while picking him or her up. C. Call the toddler's name and say, "I'm your nurse." D. Stand by the toddler, addressing him or her by name.

A. Assume position at the childs level

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. What 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.

ANS: B, C

When the nurse interviews an adolescent, which is especially important? 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 Adolescents, like all children, need an opportunity to express their feelings.

Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age? A. 1 month B. 3 to 4 months C. 6 to 8 months D. 12 months

B Binocularity is usually achieved by ages 3 to 4 months.

What is the earliest age at which a satisfactory radial pulse can be taken in children? A. 1 year B. 2 years C. 3 years D. 6 years

B Satisfactory radial pulses can be used in children older than 2 years.

Which is most important to document about immunizations in the child's health history? A. Dosage of immunizations received B. Occurrence of any reaction after an immunization C. The exact date the immunizations were received D. Practitioner who administered the immunizations

B The occurrence of any reaction after an immunization was given is the most important to document in a history because of possible future reactions, especially allergic reactions.

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 child when parent is not present.

B Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse).

Which communication technique should the nurse avoid when interviewing children and their families? A. Using silence B. Using clichés C. Directing the focus D. Defining the problem

B Using stereotyped comments or clichés can block effective communication, and this technique should be avoided

A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age? A. 1 month B. 6 to 9 months C. 1 to 2 years d. 2 1/2 to 3 years

C 1-2 years equal out

A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates 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 Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight.

Which is most likely to encourage parents to talk about their feelings related to their child's illness? A.Be sympathetic. B. Use direct questions. C. Use open-ended questions. D. Avoid periods of silence.

C Closed-ended questions should be avoided when attempting to elicit parents' feelings.

What is an appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child? A. The Rinne test B. The Weber test C. Conventional audiometry D. Eliciting the startle reflex

C Conventional audiometry is a behavioral test that measures auditory thresholds in response to speech and frequency-specific stimuli presented through earphones.

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 Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.

A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? A. Toddler B. Preschooler C. School-age child D. Adolescent

C School-age children have a heightened concern about body integrity.

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? A. Teach parents appropriate exercises. B. Recheck head control at next visit. C. Refer child for further evaluation. D. Refer child for further evaluation if anterior fontanel is still open.

C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation.

Which is the most appropriate vision acuity test for a child who is in preschool? A. Cover test B. Ishihara test C. HOTV chart D. Snellen letter chart

C The HOTV test consists of a wall chart of these letters.

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 The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present.

What is the single most important factor to consider when communicating with children? A. The child's physical condition B. Presence or absence of the child's parent C. The child's developmental level D. The child's nonverbal behaviors

C The nurse must be aware of the child's developmental stage to engage in effective communication.

The nurse is testing an infant's 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 Visual fixation and following a target should be present by ages 3 to 4 months.

A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess? a. Rubs b. Rattles c. Wheezes d. Crackles

C Wheezes

At what age should the nurse expect the anterior fontanel to close? A. 2 months B. 2 to 4 months C. 6 to 8 months D. 12 to 18 months

D 12-18

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might 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 if the child is always uncommunicative. D. Ask the child to draw a picture.

D Drawing is one of the most valuable forms of communication.

Which following parameters correlates best with measurements of the body's total protein stores? A. Height B. Weight C. Skinfold thickness D. Upper arm circumference

D Upper arm circumference is correlated with measurements of total muscle mass.

Pulses can be graded according to certain criteria. Which is a description of a normal pulse? a. 0 b. +1 c. +2 d. +3

D normal pulse = +3