Pedi chap 4 TB

a. A normal finding

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 which? a. A normal finding b. A sign of a possible visual defect and a need for vision screening c. An abnormal finding requiring referral to an ophthalmologist d. A sign of small hemorrhages, which usually resolve spontaneously

c. Schedule the child for further evaluation.

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

c. An abnormal finding warranting investigation

When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as? a. Suggestive of chronic pulmonary disease b. Suggestive of impending respiratory failure c. An abnormal finding warranting investigation d. A normal finding in infants younger than 1 year of age

b. Allow an opportunity to express feelings.

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. Use the same type of language as the adolescent. d. Emphasize that confidentiality will always be maintained.

c. Oral mucosa

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. Murmur

Which 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 and S2 b. S3 and S4 c. Murmur d. Physiologic splitting

a. Snellen letter chart

Which is the most frequently used test for measuring visual acuity? a. Snellen letter chart b. Ishihara vision test c. Allen picture card test d. Denver eye screening test

c. Child's developmental level

Which is the single most important factor to consider when communicating with children? a. Presence of the child's parent b. Child's physical condition c. Child's developmental level d. Child's nonverbal behaviorsWhich is the single most important factor to consider when communicating with children?

d. Upper arm circumference

Which parameter correlates best with measurements of total muscle mass? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference

c. 85th percentile

With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight? a. 10th percentile b. 75th percentile c. 85th percentile d. 95th percentile

d. Normal because the lower back and leg muscles are not yet well developed.

During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which? 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. Inspection, auscultation, percussion, and palpation

Examination of the abdomen is performed correctly by the nurse in which order? a. Inspection, palpation, percussion, and auscultation b. Inspection, percussion, auscultation, and palpation c. Palpation, percussion, auscultation, and inspection d. Inspection, auscultation, percussion, and palpation

b. Refer for immediate medical evaluation.

The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action? a. Ask the parent when the neck was injured. b. Refer for immediate medical evaluation. c. Continue assessment to determine the cause of the neck pain. d. Record "head lag" on the assessment record and continue the assessment of the child.

d. Palpate the nail bed with pressure to produce a slight blanching.

The nurse is assessing a child's capillary refill time. This can be accomplished by doing what? a. Inspect the chest. b. Auscultate the heart. c. Palpate the apical pulse. d. Palpate the nail bed with pressure to produce a slight blanching.

c. Vesicular d. Bronchial e. Bronchovesicular

The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) a. Wheezes b. Crackles c. Vesicular d. Bronchial e. Bronchovesicular

a. S4 heart sound c. Grade II murmur e. S2 louder than S1 in the aortic area

The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.) a. S4 heart sound b. S3 heart sound c. Grade II murmur d. S1 louder at the apex of the heart e. S2 louder than S1 in the aortic area

c. Pure tone audiometry

What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child? a. Rinne test b. Weber test c. Pure tone audiometry d. Eliciting the startle reflex

b. Side of the tongue

What is the appropriate placement of a tongue blade for assessment of the mouth and throat? a. On the lower jaw b. Side of the tongue c. Against the soft palate d. Center back area of the tongue

b. 2 years

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

a. Lightly brush the palate with a cotton swab. b. Perform the examination in front of a mirror. c. Let the child examine someone else's mouth first. d. Have the child breathe deeply and hold his or her breath.

The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) a. Lightly brush the palate with a cotton swab. b. Perform the examination in front of a mirror. c. Let the child examine someone else's mouth first. d. Have the child breathe deeply and hold his or her breath. e. Use a tongue blade to help the child open his or her mouth.

b. A well-defined light reflex c. A small, round, concave spot near the center of the drum e. A whitish line extending from the umbo upward to the margin of the membrane

The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.) a. Ashen gray areas b. A well-defined light reflex c. A small, round, concave spot near the center of the drum d. The tympanic membrane is a nontransparent grayish color e. A whitish line extending from the umbo upward to the margin of the membrane

c. 3 to 4 months

The nurse is testing an infant's visual acuity. By which 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

a. Socializing c. Using clichés d. Defending a situation

The nurse understands that blocks to therapeutic communication include what? (Select all that apply.) a. Socializing b. Use of silence c. Using clichés d. Defending a situation e. Using open-ended questions

a. The child may think the equipment is alive.

The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? a. The child may think the equipment is alive. b. Explaining the equipment will only increase the child's fear. c. One brief explanation will be enough to reduce the child's fear. d. The child is too young to understand what the equipment does.