Principles of Pediatric Nursing 6th Ed By Ball – Test Bank

 

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Ball/Bindler/Cowen, Principles of Pediatric Nursing: Caring for Children 6th Edition Test Bank
Chapter 5

Question 1

Type: MCSA

The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family?

1. “Does any member of your family have a history of asthma, heart disease, or diabetes?”
2. “Hello, I would like to talk with you and get some information on you and your child.”
3. “Tell me about the concerns that brought you to the clinic today.”
4. “You will need to fill out these forms; make sure that the information is as complete as possible.”

Correct Answer: 3

Rationale 1: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent’s perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Rationale 2: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent’s perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Rationale 3: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent’s perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Rationale 4: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent’s perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Global Rationale: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent’s perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.2 Apply communication strategies to improve the quality of historical data collected.

 

Question 2

Type: MCSA

When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old?

1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was.
2. Ask the child to repeat his address.
3. Ask the child to say a poem and listen to the child’s speech articulation.
4. Have the child point to various parts of the body as you name them.

Correct Answer: 2

Rationale 1: Repeating the name of an object after 5–10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Rationale 2: Repeating the name of an object after 5–10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Rationale 3: Repeating the name of an object after 5–10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Rationale 4: Repeating the name of an object after 5–10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Global Rationale: Repeating the name of an object after 5–10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.1 Describe the elements of a health history for infants and children of different ages.

 

Question 3

Type: SEQ

Place the nursing assessments of a toddler in the best order.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Examination of eyes, ears, and throat

Choice 2. Auscultation of chest

Choice 3. Palpation of abdomen

Choice 4. Developmental assessment

Correct Answer: 4,2,3,1

Rationale 1: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Rationale 2: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Rationale 3: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Rationale 4: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Global Rationale: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.4 Describe the differences in sequence of the physical assessment for infants, children, and adolescents.

 

Question 4

Type: MCSA

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process?

1. Cardiac
2. Respiratory
3. Gastrointestinal
4. Genitourinary

Correct Answer: 3

Rationale 1: This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 2: This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 3: This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Rationale 4: This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Global Rationale: This infant’s sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 5

Type: MCSA

A nurse caring for a school-age client notices some swelling in the child’s ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate?

1. Skin integrity, especially in the lower extremities
2. Urine output
3. Level of consciousness
4. Range of motion and ankle mobility

Correct Answer: 2

Rationale 1: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 2: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 3: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Rationale 4: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

Global Rationale: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 6

Type: MCSA

A new mother is worried about a “soft spot” on the top of her newborn infant’s head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close?

1. 2 to 3 months of age
2. 6 to 9 months of age
3. 12 to 18 months of age
4. Approximately 2 years of age

Correct Answer: 3

Rationale 1: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Rationale 2: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Rationale 3: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Rationale 4: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Global Rationale: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 5.1 Describe the elements of a health history for infants and children of different ages.

 

Question 7

Type: MCSA

While inspecting a 5-year-old child’s ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority?

1. Temperature
2. Heart rate
3. Respirations
4. Blood pressure

Correct Answer: 1

Rationale 1: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Rationale 2: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Rationale 3: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Rationale 4: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

Global Rationale: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention..

 

Question 8

Type: MCMA

A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings?

Standard Text: Select all that apply.

1. Wheezing
2. Increased tactile fremitus
3. Decreased vocal resonance
4. Decreased tactile fremitus
5. Bronchophony

Correct Answer: 1,3,4

Rationale 1: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 2: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 3: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 4: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Rationale 5: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Global Rationale: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 9

Type: MCSA

The nurse is caring for a newly-admitted infant diagnosed with “failure to thrive.” The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order?

1. Tetralogy of Fallot
2. Pulmonary atresia
3. Coarctation of the aorta
4. Ventricular septal defect

Correct Answer: 3

Rationale 1: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Rationale 2: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Rationale 3: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Rationale 4: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Global Rationale: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 10

Type: MCSA

During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action?

1. Recent memory
2. Language development
3. Remote memory
4. Social-skill development

Correct Answer: 3

Rationale 1: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child’s language development, and assessing how he interacts with others evaluates social-skill development.

Rationale 2: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child’s language development, and assessing how he interacts with others evaluates social-skill development.

Rationale 3: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child’s language development, and assessing how he interacts with others evaluates social-skill development.

Rationale 4: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child’s language development, and assessing how he interacts with others evaluates social-skill development.

Global Rationale: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child’s language development, and assessing how he interacts with others evaluates social-skill development.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.2 Apply communication strategies to improve the quality of historical data collected.

 

Question 11

Type: MCSA

During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be:

1. soles are flat with prominent fat pads.
2. positive Babinski reflex.
3. metatarsus varus.
4. asymmetric thigh and gluteal folds.

Correct Answer: 4

Rationale 1: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Rationale 2: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Rationale 3: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Rationale 4: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in-toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow-up with ultrasound.

Global Rationale:

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 12

Type: MCSA

The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first?

1. A child with a temperature of 101 degrees F
2. A child who has stridor
3. A child who has absent Babinski sign
4. A child who has a pot belly appearance

Correct Answer: 2

Rationale 1: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.

Rationale 2: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.

Rationale 3: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.

Rationale 4: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.

Global Rationale: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 13

Type: MCSA

The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to:

1. hear a quiet but easily heard murmur.
2. hear a moderately loud murmur without a palpable thrill.
3. hear a very loud murmur with easily palpable thrill.
4. listen without a stethoscope and hear a murmur at chest wall.

Correct Answer: 2

Rationale 1: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Rationale 2: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Rationale 3: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Rationale 4: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

Global Rationale: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI.

 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: LO 5.8 Distinguish between expected and unexpected physical signs to identify at least five signs that require urgent nursing intervention.

 

Question 14

Type: MCSA

The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child’s abdomen where the tape measure should be placed for an accurate abdominal girth.

1. Just above the umbilicus, around the largest circumference of the abdomen
2. Below the umbilicus
3. Just below the sternum
4. Just above the pubic bone

Correct Answer: 1

Rationale 1: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Rationale 2: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Rationale 3: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Rationale 4: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

Global Rationale: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth.

 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.5 Modify physical assessment techniques according to the age and developmental stage of the child.

 

Question 15

Type: MCMA

 

The nurse is preparing to assessment a toddler client. Which activities would gain cooperation from the toddler?

Standard Text: Select all that apply.

1. Asking the parents to wait outside
2. Allowing the client to sit in the parent’s lap
3. Administering vaccinations prior to the assessment
4. Handing the client a stethoscope while taking the health history
5. Making a game out of the assessment process

Correct Answer: 2,4

Rationale 1: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler’s cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

Rationale 2: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler’s cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

Rationale 3: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler’s cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

Rationale 4: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler’s cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

Rationale 5: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler’s cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

Global Rationale: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler’s cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.3 Demonstrate strategies to gain cooperation of a young child for assessment.

 

Question 16

Type: MCMA

 

The nurse is assessing an infant client during a health supervision visit. Which assessment findings are considered normal variations for this client?

Standard Text: Select all that apply.

1. Sucking pads in the mouth
2. A rounded chest
3. Hearing breath sounds over the entire chest
4. Pubertal development
5. Knock-knees

Correct Answer: 1,2,3

Rationale 1: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

Rationale 2: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

Rationale 3: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

Rationale 4: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

Rationale 5: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

Global Rationale: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5.6 List five normal variations in pediatric physical findings (such as a hyperpigmented spot in an infant) found during a physical assessment.

 

Question 17

Type: MCMA

 

The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infant’s growth pattern since birth?

Standard Text: Select all that apply.

1. Weight the infant twice and average together
2. Measure the infant’s height
3. Measure the infant’s head circumference
4. Determine the infant’s body mass index
5. Plot the infant’s growth on appropriate chart

Correct Answer: 1,3,5

Rationale 1: In order to determine the infant’s growth pattern the nurse will obtain two weights and average them together, measure the infant’s head circumference, and obtain the infant’s length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant’s growth pattern. Body mass index is not determined during infancy.

Rationale 2: In order to determine the infant’s growth pattern the nurse will obtain two weights and average them together, measure the infant’s head circumference, and obtain the infant’s length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant’s growth pattern. Body mass index is not determined during infancy.

Rationale 3: In order to determine the infant’s growth pattern the nurse will obtain two weights and average them together, measure the infant’s head circumference, and obtain the infant’s length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant’s growth pattern. Body mass index is not determined during infancy.

Rationale 4: In order to determine the infant’s growth pattern the nurse will obtain two weights and average them together, measure the infant’s head circumference, and obtain the infant’s length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant’s growth pattern. Body mass index is not determined during infancy.

Rationale 5: In order to determine the infant’s growth pattern the nurse will obtain two weights and average them together, measure the infant’s head circumference, and obtain the infant’s length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant’s growth pattern. Body mass index is not determined during infancy.

Global Rationale: In order to determine the infant’s growth pattern the nurse will obtain two weights and average them together, measure the infant’s head circumference, and obtain the infant’s length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant’s growth pattern. Body mass index is not determined during infancy.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: LO 5 5.7 Evaluate the growth pattern of an infant or child.