Question 1

During a funduscopic examination of a school-age child, the nurse notes presence of a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which of the following?

Accepted Answer

A)  Normal finding
B)  Abnormal finding, so child needs referral to ophthalmologist
C)  Sign of possible visual defect, so child needs vision screening
D)  Sign of small hemorrhages, which will usually resolve spontaneously A

Question 2

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for which of the following?

Accepted Answer

A)  Deep tendon reflexes
B)  Cerebellar function
C)  Sensory discrimination
D)  Ability to follow directions

Question 3

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?

Accepted Answer

A)  1 month
B)  1 to 2 months
C)  3 to 4 months
D)  6 months

Question 4

What is the earliest age at which a satisfactory radial pulse can be taken in children?

Accepted Answer

A)  1 year
B)  2 years
C)  3 years
D)  6 years

Question 5

Pulses can be graded according to certain criteria. Which of the following is a description of a normal pulse?

Accepted Answer

A)  0
B)  +1
C)  +2
D)  +3

Question 6

Which one of the following tools measures body fat most accurately?

Accepted Answer

A)  Stadiometer
B)  Calipers
C)  Cloth tape measure
D)  Paper or metal tape measure

Question 7

The nurse must do vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Select all the criteria the nurse should use in determining the appropriate-size blood pressure cuff.

Accepted Answer

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.

Question 8

Rectal temperatures are indicated in which of the following situations?

Accepted Answer

A)  In the newborn period
B)  Whenever accuracy is essential
C)  When no other route or device can be used
D)  When rapid temperature changes are occurring

Question 9

By what age do the head and chest circumferences generally become equal?

Accepted Answer

A)  1 month
B)  6 to 9 months
C)  1 to 2 years
D)  2 1/2 to 3 years

Question 10

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

Accepted Answer

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

Question 11

The appropriate placement of a tongue blade for assessment of the mouth and throat is which of the following?

Accepted Answer

A)  Center back area of tongue
B)  Side of the tongue
C)  Against the soft palate
D)  On the lower jaw

Question 12

With the National Center for Health Statistics (NCHS)  criteria, which one of the following body mass index (BMI) -for-age percentiles would be at risk for overweight?

Accepted Answer

A)  10th percentile
B)  9th percentile
C)  85th percentile
D)  95th percentile

Question 13

The nurse is administering the Denver II to a 16-week-old infant who was born 4 weeks early. At what age should the infant be tested?

Accepted Answer

A)  10 weeks
B)  12 weeks
C)  16 weeks
D)  18 weeks B

Question 14

The nurse is beginning to administer the Denver II to a small child when his mother says, "Can you tell me again what this Denver II is?" The nurse's best response is which of the following?

Accepted Answer

A)  "It's a simple intelligence test of young children."
B)  "It tells us what a child can do at a particular age."
C)  "It's a test we give to measure a child's development."
D)  "It's an excellent way to see if a child's development is normal."

Question 15

The nurse must assess a child's capillary filling time. This can be accomplished by doing which of the following?

Accepted Answer

A)  Inspect the chest.
B)  Auscultate the heart.
C)  Palpate the apical pulse.
D)  Palpate the skin to produce a slight blanching.

Question 16

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos)  with pain on flexion. Which of the following is the most appropriate action?

Accepted Answer

A)  Refer for immediate medical evaluation.
B)  Continue assessment to determine cause of neck pain.
C)  Ask parent when neck was injured.
D)  Record "head lag" on assessment record, and continue assessment of child.

Question 17

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Accepted Answer

A)  Sl, S2
B)  S3, S4
C)  Murmur
D)  Physiologic splitting

Question 18

At what age should the nurse expect the anterior fontanel to close?

Accepted Answer

A)  2 months
B)  2 to 4 months
C)  6 to 8 months
D)  12 to 18 months D

Question 19

When auscultating an infant's lungs, the nurse detects diminished breath sounds. The nurse should interpret this as which of the following?

Accepted Answer

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

Question 20

Which of the following is an appropriate approach to performing a physical assessment on a toddler?

Accepted Answer

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.

Exam 7: Physical and Developmental Assessment of the Child

During a funduscopic examination of a school-age child, the nurse notes presence of a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which of the following?

Correct AnswerverifiedA

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for which of the following?

Correct AnswerverifiedShow Answer

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?

Correct AnswerverifiedShow Answer

What is the earliest age at which a satisfactory radial pulse can be taken in children?

Correct AnswerverifiedShow Answer

Pulses can be graded according to certain criteria. Which of the following is a description of a normal pulse?

Correct AnswerverifiedShow Answer

Which one of the following tools measures body fat most accurately?

Correct AnswerverifiedShow Answer

The nurse must do vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Select all the criteria the nurse should use in determining the appropriate-size blood pressure cuff.

Correct AnswerverifiedShow Answer

Rectal temperatures are indicated in which of the following situations?

Correct AnswerverifiedShow Answer

By what age do the head and chest circumferences generally become equal?

Correct AnswerverifiedShow Answer

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

Correct AnswerverifiedShow Answer

The appropriate placement of a tongue blade for assessment of the mouth and throat is which of the following?

Correct AnswerverifiedShow Answer

With the National Center for Health Statistics (NCHS) criteria, which one of the following body mass index (BMI) -for-age percentiles would be at risk for overweight?

Correct AnswerverifiedShow Answer

The nurse is administering the Denver II to a 16-week-old infant who was born 4 weeks early. At what age should the infant be tested?

Correct AnswerverifiedB

The nurse is beginning to administer the Denver II to a small child when his mother says, "Can you tell me again what this Denver II is?" The nurse's best response is which of the following?

Correct AnswerverifiedShow Answer

The nurse must assess a child's capillary filling time. This can be accomplished by doing which of the following?

Correct AnswerverifiedShow Answer

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which of the following is the most appropriate action?

Correct AnswerverifiedShow Answer

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Correct AnswerverifiedShow Answer

At what age should the nurse expect the anterior fontanel to close?

Correct AnswerverifiedD

When auscultating an infant's lungs, the nurse detects diminished breath sounds. The nurse should interpret this as which of the following?

Correct AnswerverifiedShow Answer

Which of the following is an appropriate approach to performing a physical assessment on a toddler?

Correct AnswerverifiedShow Answer

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B

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D

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