What is the best way to approach a toddler when performing a physical assessment Quizlet

MATCHING
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
b. Palpation
c. Inspection
d. Percussion

47. Step 1 -> c
48. Step 2 -> a
49. Step 3 -> d
50. Step 4 ->b

47. ANS: C PTS:
1 DIF: Cognitive Level: Application
REF: 818 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
NOT: The correct order of abdominal examination is inspection, auscultation, percussion, and palpation.
Palpation is always performed last because it may distort the normal abdominal sounds.
48. ANS: A PTS: 1 DIF: Cognitive Level: Application
REF: 819 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
NOT: The correct order of abdominal examination is inspection, auscultation, percussion, and palpation.
Palpation is always performed last because it may distort the normal abdominal sounds.
49. ANS: D PTS: 1 DIF: Cognitive Level: Application
REF: 827 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
NOT: The correct order of abdominal examination is inspection, auscultation, percussion, and palpation.
Palpation is always performed last because it may distort the normal abdominal sounds.
50. ANS: B PTS: 1 DIF: Cognitive Level: Application
REF: 819 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 474
NOT: The correct order of abdominal examination is inspection, auscultation, percussion, and palpation.
Palpation is always performed last because it may distort the normal abdominal sounds.

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Terms in this set (37)

Physical Assessment of Children
1. The nurse percussing over an empty stomach expects to hear which sound?
a. Tympany
b. Resonance
c. Flatness
d. Dullness

ANS: A
Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle. Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 720 | Box 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
2. The nurse is admitting a toddler to the pediatric infectious disease unit. What is the single most important component of the child's physical examination?
a. Assessment of heart and lungs
b. Measurement of height and weight
c. Documentation of parental concerns
d. Obtaining an accurate history

ANS: D
An accurate history is most helpful in identifying problems and potential problems. Heart and lung assessment is not as important as an accurate history. A single measurement of height and weight is not as significant as determining growth over time. The child's growth pattern can be elicited from the history. Documentation of parental concerns is not as relevant to the physical examination as an accurate history in this case.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 720 | Box 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity

Physical Assessment of Children
3. In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea?
a. Review of systems
b. Chief complaint
c. Lifestyle and life patterns
d. Health history

ANS: B
The chief complaint is documented using the child's or parent's words for the reason the child was brought to the health care center. The review of systems includes health functions of body systems. Lifestyle and life patterns include the child's interaction with the social, psychological, physical, and cultural environment. Health history includes birth history, growth and development, common childhood illnesses, immunizations, hospitalizations, injuries, and allergies.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 721 | Box 33.4 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity

Physical Assessment of Children
4. The nurse assesses a child's oculomotor, trochlear, and abducent nerves by using which technique?
a. Assessing the six cardinal gazes
b. Identification of common odors
c. Having child bite on a tongue blade
d. Ask child to shrug against resistance

ANS: A
Using the six cardinal gazes the nurse assesses the oculomotor, trochlear, and abducent nerves. Odors are detected by the olfactory nerve. Biting on tongue blade assesses the trigeminal nerve. Shrugging against resistance assesses the accessory nerve.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 745 | Table 33.4 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
5. The nurse is performing a comprehensive physical examination on a young child in the hospital. At what age can the nurse expect a child's head and chest circumferences to be almost equal?
a. Birth
b. 6 months
c. 1 year
d. 3 years

ANS: C
Head and chest measurements are almost equal at 1 year of age.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 724 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
6. 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.

ANS: C
School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. "Why" questions are not therapeutic, plus this question makes it sound like the nurse thinks the child does not need this information. The child is not exhibiting anxiety, just requesting clarification of what will be occurring. The nurse must explain how the blood pressure cuff works so that the child can then observe during the procedure.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 719 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity

Physical Assessment of Children
7. Which chart should the nurse use to assess the visual acuity of an 8-year-old child?
a. Lea chart
b. Snellen chart
c. HOTV chart
d. Tumbling E chart

ANS: B
The Snellen chart is used to assess the vision of children older than 6 years of age. The Lea chart tests vision using four different symbols designed for use with preschool children. The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years. The tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 731 | Box 33.8 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
8. Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child?
a. Ask the parent to quiet the child so the nurse can listen.
b. Auscultate breath sounds and chart that the child was crying.
c. Let the child play with the stethoscope for distraction.
d. Document that data are not available because of crying.

ANS: C
Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made. Asking a parent to quiet the child may or may not work. Auscultating while the child is crying typically results in less than optimal data. The assessment needs to be completed so documenting that data are not available is not appropriate.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 735 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
9. The nurse is obtaining vital signs on a 1-year-old child. What is the most appropriate site for assessing the pulse rate?
a. Apical
b. Radial
c. Carotid
d. Femoral

ANS: A
Apical pulse rates are taken in children younger than 2 years. Radial pulse rates may be taken in children older than 2 years. It is difficult to palpate the carotid pulse in an infant. The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infant's pulse rate.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 722 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
10. A nurse is reviewing pediatric physical assessment techniques. Which statement about performing a pediatric physical assessment is correct?
a. Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise.
b. The physical examination should be done with parents in the examining room for children of any age.
c. Measurement of head circumference is done until the child is 5 years old.
d. The physical examination is done only when the child is cooperative.

ANS: A
Physical assessment usually proceeds from head to toe; however, developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data. Having parents in the examining room with adolescents is not appropriate. Head circumference is routinely measured until 36 months of age. Children will not always be cooperative during the physical examination. The examiner will need to incorporate communication and play techniques to facilitate cooperation.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 718 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
11. What term should be used in the nurse's documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration?
a. Pleural friction rub
b. Sonorous rhonchi
c. Crackles
d. Wheeze

ANS: C
Crackles are short, popping, discontinuous sounds heard on inspiration. Sonorous rhonchi are low-pitched, moaning, musical sounds. A pleural friction rub has a grating, coarse, low-pitched sound. Wheezes are musical, high-pitched, predominant sounds heard on expiration.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 737 | Table 33.2 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
12. Which strategy is the best approach when initiating the physical examination of a 9-month-old male infant?
a. Undress the infant and do a head-to-toe examination.
b. Have the parent hold the child on his or her lap.
c. Put the infant on the examination table and begin assessments at the head.
d. Ask the parent to leave because the infant will be upset.

ANS: B
Toddlers may be resistant and uncooperative. The nurse allows the child to remain on the parent's lap to ease anxiety. The head-to-toe approach needs to be modified for the infant. Uncomfortable procedures, such as the otoscopic examination, should be left until last. There is no reason to ask a parent to leave when an infant is being examined. Having the parent with the infant will make the experience less upsetting for the infant.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: pp. 718-719 | Figure 33.1 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
13. Which strategy is not always appropriate for pediatric physical examination?
a. Take the history in a quiet, private place.
b. Examine the child from head to toe.
c. Exhibit sensitivity to cultural needs and differences.
d. Perform frightening procedures last.

ANS: B
The classic approach to physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner must tailor the physical assessment to the child's age and developmental level. The nurse should collect the child's health history in a quiet, private area. The nurse should always be sensitive to cultural needs and differences among children. When examining children, painful or frightening procedures should be left to the end of the examination.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 719 | Nursing Quality Alert Box OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
14. Which assessment should the nurse perform last when examining a 5-year-old child?
a. Heart
b. Lungs
c. Abdomen
d. Throat

ANS: D
Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination. Examination of the heart, lungs, and abdomen are seen as less threatening.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 719 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
15. When is the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old girl?
a. It is not necessary to inspect the genital area.
b. Examine the genital area first.
c. After the abdominal assessment
d. Do the genital inspection last.

ANS: C
It is best to incorporate the genital assessment into the middle of the examination. This allows ample time for questions and discussion. If possible, proceed from the abdominal area to the genital area. A visual inspection of all areas of the body is included in a physical examination. Examination of the genital area can be embarrassing. It is not appropriate to begin the examination with this area. Assessing the genital area earlier in the examination allows more time for the adolescent to ask questions and engage in discussion.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 719 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
16. Which measurement is not indicated for a 4-year-old well-child examination?
a. Blood pressure
b. Weight
c. Height
d. Head circumference

ANS: D
Head circumference is measured on all children from birth to 3 years. Children older than 3 years of age with questionable head size or a history of megalocephaly, hydrocephalus, or microcephaly should have their head circumference assessed at every visit. A 4-year-old without a history of these problems does not need his or her head circumference measured. Blood pressure, weight, and height measurements are taken on all children at every ambulatory visit.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 724 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
17. The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or violet color. This skin coloration is associated with what?
a. Cyanosis
b. Erythema
c. Vitiligo
d. Nevi

ANS: B
In dark-skinned children, erythema appears as dusky red or violet skin coloration. Cyanosis in a dark-skinned child appears as a black coloration of the skin. Vitiligo refers to areas of depigmentation. Nevi are areas of increased pigmentation.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 725 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
18. The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed. What does this finding indicate?
a. This is a normal finding.
b. This finding indicates premature closure of cranial sutures.
c. This is abnormal, and the child should have a developmental evaluation.
d. This is an abnormal finding, and the child should have a neurologic evaluation.

ANS: A
The anterior fontanel should be completely closed by 12 to 18 months of age. It does not mean premature closure or indicate a need for developmental or neurologic evaluations.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 727 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
19. The nurse is assessing a 4-year-old child's visual acuity. The results indicate a visual acuity of 20/40 in both eyes. The child's father asks the nurse about his son's results. Which response, if made by the nurse, is correct?
a. "Your child will need a referral to the ophthalmologist before he can attend preschool next week."
b. "Your child's visual acuity is normal for his age."
c. "The results of this test indicate your child may be color blind."
d. "Your child did not pass; he will need to see an eye doctor."

ANS: B
Normal visual acuity for a 4-year-old is 20/40 to 20/50. This finding is normal. No other action is needed.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 732 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
20. When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones. This should be considered
a. unnecessary information, because the child is 3 years old.
b. an important part of the family history.
c. an important part of the child's past growth and development.
d. an important part of the child's review of systems.

ANS: C
Information about the attainment of developmental milestones is necessary and important to obtain. It provides data about the child's growth and development that should be included in the history. Developmental milestones provide important information about the child's physical, social, and neurologic health. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings should be included in the family history. The review of systems does not include the developmental milestones.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 721 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
21. Which cranial nerve is assessed when the child is asked to imitate the examiner's wrinkled frown, wrinkled forehead, smile, and raised eyebrow?
a. Accessory
b. Hypoglossal
c. Trigeminal
d. Facial

ANS: D
The facial nerve is assessed as described in the question. To assess the accessory nerve, the examiner palpates and notes the strength of the trapezius and sternocleidomastoid muscles against resistance. To assess the hypoglossal nerve, the examiner asks the child to stick out the tongue. To assess the trigeminal nerve, the child is asked to identify a wisp of cotton on the face. The corneal reflex and temporal and masseter muscle strength are evaluated.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 727
OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
22. Which assessment finding is considered a neurologic soft sign in a 7-year-old child?
a. Plantar reflex
b. Poor muscle coordination
c. Stereognostic function
d. Graphesthesia

ANS: B
Poor muscle coordination is a neurologic soft sign. The plantar reflex is a normal response. Stereognostic function refers to the ability to identify familiar objects placed in each hand. Graphesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 746 | Box 33.13 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
23. Which parameter correlates best with measurements of the body's total muscle mass-to-fat ratio?
a. Height
b. Weight
c. Skinfold thickness
d. Mid-arm circumference

ANS: D
The mid-arm circumference reflects muscle and fat. Height, weight, and skinfold thickness do not reflect muscle and fat.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 724 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
24. Which tool measures body fat most accurately?
a. Measuring board
b. Calipers
c. Cloth tape measure
d. Paper or metal tape measure

ANS: B
Calipers are used to measure skinfold thickness, which is an indicator of body fat content. A measuring board is used to determine an infant or a toddler's height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 724 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
25. When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?
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

ANS: D
Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. They are not indicative of cancer or scalp infection.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 726 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
26. 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. Snaps and clicks
c. Murmur
d. Physiologic splitting

ANS: C
Murmurs are the sounds that are produced in the heart chambers or major arteries from the turbulence of blood flow. Murmurs create a blowing and swooshing sound. S1 and S2 are the normal heart sounds. Snaps and clicks are short, high-pitched sounds heard with valve disorders and do not vary with respirations. The physiologic splitting of S2, an audible pause between the closing of the aortic and pulmonic valves, frequently heard in children of all ages, is considered normal.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 737 | Table 33.2 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

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

ANS: D
The correct order of abdominal examination is inspection, auscultation, and palpation. If the nurse percusses the abdomen, that is done prior to palpation. Palpation is always last because it may distort the normal abdominal sounds.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 739 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
28. The nurse has a 2-year-old boy sit in a "tailor" position during palpation for the testes. What is the rationale for this position?
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.

ANS: A
The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its contraction, which pulls the testes into the pelvic cavity.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 741 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
29. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is
a. abnormal, requiring 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.

ANS: D
Genu varum (bowlegged) is common in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are well developed, usually by age 3.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 743 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
30. 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.

ANS: B
The finger-to-nose-test is an indication of cerebellar function. This test checks balance and coordination. It does not assess DTRs, sensory discrimination, or the ability to follow directions.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 746 | Box 33.11 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
31. A nurse is assessing a 12-month-old baby. What question about growth and development is most appropriate?
a. Can the baby roll over?
b. Does your baby pull himself up?
c. Is your baby cruising around yet?
d. Will your baby sit alone?

ANS: C
Cruising should occur by 12 months. Rolling over occurs by 3 to 6 months. A baby will pull herself up by around 11 months. Sitting alone occurs by 7 months.

PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 745 | Table 33.3 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
32. A student nurse hears two registered nurses discussing a child who has neurologic soft signs. The student asks what this means. What response by the nurse is best?
a. The baby's fontanels have not yet closed.
b. Tests of neurologic function are indeterminate.
c. The child can't perform activities he should be able to.
d. The child has a significant neurologic disorder.

ANS: C
A neurologic soft sign indicates the child's inability to perform certain activities related to the child's age. They may provide subtle clues to an underlying central nervous system deficit or neurologic maturation delay. They require more evaluation. They are not related to fontanels or indeterminate findings.

PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 746 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
1. Which statements about performing a pediatric physical assessment are correct for a school-age child? (Select all that apply.)
a. Physical examinations proceed systematically from head to toe.
b. The physical examination should be done with parents in the waiting room.
c. Measurement of head circumference is obtained.
d. The physical examination is done only when the child is cooperative.
e. Remove clothing and have the child put on an examination gown.

ANS: A, D, E
Physical assessment usually proceeds from head to toe; however, if developmental delays exist, considerations dictate that the least threatening assessments be done first to obtain accurate data. School-age children are at a developmental stage when they should be cooperative for the physical examination. Children of this age are usually modest, and an examination gown should be provided. Having parents in the examining room with adolescents is not appropriate, but it is appropriate for children of other age-groups. Parents usually are not kept in the waiting room. Measurement of head circumference is obtained on children 36 months of age or less.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 719 OBJ: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
2. What should the nurse recognize as a possible indicator of child abuse in a 4-year-old child being treated for ear pain at the emergency department on a cold winter day? (Select all that apply.)
a. The child extends his arms to be hugged by the nurse.
b. The child is wearing clean, baggy shorts, sandals, and an oversized T-shirt.
c. The child answers all questions in complete sentences and smiles afterward.
d. The child has dirty, broken teeth.
e. The child states "I'm so fat" when the nurse tells his mother he weighs 25 lb.

ANS: B, D, E
These clothes are inappropriate for the weather and possibly too big. Dirty, broken teeth possibly show neglect of basic needs. Body image distortion is another possible clue to child abuse. Although it may be unusual for this child to want to be hugged by the nurse, it is not an indicator of child abuse. Answering questions using complete sentences and smiling is appropriate for a 4-year-old.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 720 | Box 33.2 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
3. A nurse is performing an assessment on a newborn. Which vital signs indicate a normal finding for this age-group? (Select all that apply.)
a. Pulse of 80 to 125 a minute
b. B/P of systolic 65 to 95 and diastolic 30 to 60
c. Temperature of 36.5 to 37.3 C (axillary)
d. Temperature of 36.4 to 37 C (axillary)
e. Respirations of 30 to 60 a minute

ANS: B, C, E
The blood pressure, temperature, and respiratory rate are all normal for this child. The pulse of 80 to 125 and the temperature of 36.4 to 37 C (axillary) are both too low for a well newborn.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 722 | Table 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
4. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply.)
a. Pain with deep palpation of the spinal column
b. Unequal shoulder heights
c. The trouser pant leg length appears shorter on one side
d. Inability to bend at the waist
e. Unequal waist angles

ANS: B, C, E
The assessment findings associated with scoliosis include unequal shoulder heights, trouser pant leg length appearing shorter on one side meaning unequal leg length, and unequal waist angles. Scoliosis is a non-painful curvature of the spine so pain is not expected and the child is able to bend at the waist adequately.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 744 | Box 33.9 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

Physical Assessment of Children
5. A nurse working with infants recognizes which findings as possible signs of brain dysfunction? (Select all that apply.)
a. Irritability
b. Nausea
c. Anorexia
d. Vomiting
e. Fever

ANS: A, C, D, E
Irritability, loss of appetite, vomiting, and fever may indicate brain dysfunction in infants. Infants cannot complain of nausea.

PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 743 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance

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