NURS 104 Test 6 (Pediatric Assessment)
UPDATED ACTUAL Exam Questions and
CORRECT Answers
1. keep the room warm and well lit
2. perform exam in nonthreatening environments. keep medical equipment out of sight
3. provide privacy. determine whether older school aged children and adolescents prefer a
caregiver to remain during exam
4. take time to play and develop rapport prior to beginning an exam
5. observe for behaviors that demonstrate child's readiness to cooperate
6. explain each step of exam to the child (age appropriate language, demonstrate what will
happen using dolls, or drawing)
7. examine the child in a secure. comfy position (lap of parent)
8. proceed to examine the child in an organized sequence (infant sleeping complete quiet exams
first)
9. if the child in uncooperative, assess reasons, be firm and direct about expected behavior,
complete the assessment quickly and use a calm voice
10. encourage child and family to ask questions during physical exams; discuss findings with
family after - CORRECT ANSWER - 10 nursing actions when examining a pediatric
patient
-axillary
-rectal is exact measurement is needed - CORRECT ANSWER - temperature devices for 1
month to 1 year
-axillary
-oral if child is cooperative
-temporal
rectal if exact measurement is needed - CORRECT ANSWER - temperature devices for 1
year to 5 years
,-oral
-axillary
-temporal
-rectal is exact measurement is needed - CORRECT ANSWER - temperature devices for 6
years to 18 years
-they start very fast and then slow as they age (blood pressure starts lows and gets higher) -
CORRECT ANSWER - what happens to the numbers of each vital sign as the patient gets
older
-appears undistressed, clean, well kept, and without body odors
-muscle tone: erect head posture is expected in infants after 4 months of age
-makes eye contact when addressed (except infants)
-follows simple commands as age appropriate
-uses speech, language and motor skills spontaneously - CORRECT ANSWER - general
appearance for child (5)
-variations in skin color are expected
-temperature should be warm or slightly cool to touch
-skin texture should be smooth and slightly dry, not oily
-skin turgor exhibits brisk elasticity with adequate hydration
-lesions are not an expected finding
-skin folds should be symmetric - CORRECT ANSWER - skin for child (6)
-the shape of the head should be symmetric
-fontanels should be flat. the posterior fontanel usually closes by 8 weeks of age, the anterior
fontanel usually closes between 12-18 months of age
, -sunken fontanels are an indicator of dehydration. bulging fontanels are an indicator of increased
intracranial pressure. however, assess while the baby is calm and quiet because crying can cause
bulging fontanels as well - CORRECT ANSWER - head for child (3)
-the external ear should be free of lesions and non tender
-the ear canal should be free of foreign bodies or discharge
-cerumen is an expected finding - CORRECT ANSWER - external ear for child (3)
-in infants and toddlers, pull the pinna down and back to visualize the tympanic membrane
-in children older than 3 years, pull the pinna up and back to visualize
-the ear canal should be pink with fine hairs
-the tympanic membrane should be pearly pink or gray
-the light reflex should be visible - CORRECT ANSWER - internal ear for child (5)
-infants: shape is almost circular with anteroposterior for diameter equalling the transverse or
lateral diameter
-children and adolescents: the transverse diameter to anteroposterior diameter changes to 2:1 -
CORRECT ANSWER - chest shape of child (2)
-symmetric, no retractions
-infants: irregular rhythms are common
-children younger than 7 years: more abdominal movement is seen during respirations -
CORRECT ANSWER - chest movement of child (3)
-vesicular, or soft, swishing sounds, are heard over most of the lungs
-will be similar sounds to an adult
-place stethoscope on chest and back same as an adult - CORRECT ANSWER - breath
sounds of child (3)
-heart sounds will be similar to the sounds heard in an adult
UPDATED ACTUAL Exam Questions and
CORRECT Answers
1. keep the room warm and well lit
2. perform exam in nonthreatening environments. keep medical equipment out of sight
3. provide privacy. determine whether older school aged children and adolescents prefer a
caregiver to remain during exam
4. take time to play and develop rapport prior to beginning an exam
5. observe for behaviors that demonstrate child's readiness to cooperate
6. explain each step of exam to the child (age appropriate language, demonstrate what will
happen using dolls, or drawing)
7. examine the child in a secure. comfy position (lap of parent)
8. proceed to examine the child in an organized sequence (infant sleeping complete quiet exams
first)
9. if the child in uncooperative, assess reasons, be firm and direct about expected behavior,
complete the assessment quickly and use a calm voice
10. encourage child and family to ask questions during physical exams; discuss findings with
family after - CORRECT ANSWER - 10 nursing actions when examining a pediatric
patient
-axillary
-rectal is exact measurement is needed - CORRECT ANSWER - temperature devices for 1
month to 1 year
-axillary
-oral if child is cooperative
-temporal
rectal if exact measurement is needed - CORRECT ANSWER - temperature devices for 1
year to 5 years
,-oral
-axillary
-temporal
-rectal is exact measurement is needed - CORRECT ANSWER - temperature devices for 6
years to 18 years
-they start very fast and then slow as they age (blood pressure starts lows and gets higher) -
CORRECT ANSWER - what happens to the numbers of each vital sign as the patient gets
older
-appears undistressed, clean, well kept, and without body odors
-muscle tone: erect head posture is expected in infants after 4 months of age
-makes eye contact when addressed (except infants)
-follows simple commands as age appropriate
-uses speech, language and motor skills spontaneously - CORRECT ANSWER - general
appearance for child (5)
-variations in skin color are expected
-temperature should be warm or slightly cool to touch
-skin texture should be smooth and slightly dry, not oily
-skin turgor exhibits brisk elasticity with adequate hydration
-lesions are not an expected finding
-skin folds should be symmetric - CORRECT ANSWER - skin for child (6)
-the shape of the head should be symmetric
-fontanels should be flat. the posterior fontanel usually closes by 8 weeks of age, the anterior
fontanel usually closes between 12-18 months of age
, -sunken fontanels are an indicator of dehydration. bulging fontanels are an indicator of increased
intracranial pressure. however, assess while the baby is calm and quiet because crying can cause
bulging fontanels as well - CORRECT ANSWER - head for child (3)
-the external ear should be free of lesions and non tender
-the ear canal should be free of foreign bodies or discharge
-cerumen is an expected finding - CORRECT ANSWER - external ear for child (3)
-in infants and toddlers, pull the pinna down and back to visualize the tympanic membrane
-in children older than 3 years, pull the pinna up and back to visualize
-the ear canal should be pink with fine hairs
-the tympanic membrane should be pearly pink or gray
-the light reflex should be visible - CORRECT ANSWER - internal ear for child (5)
-infants: shape is almost circular with anteroposterior for diameter equalling the transverse or
lateral diameter
-children and adolescents: the transverse diameter to anteroposterior diameter changes to 2:1 -
CORRECT ANSWER - chest shape of child (2)
-symmetric, no retractions
-infants: irregular rhythms are common
-children younger than 7 years: more abdominal movement is seen during respirations -
CORRECT ANSWER - chest movement of child (3)
-vesicular, or soft, swishing sounds, are heard over most of the lungs
-will be similar sounds to an adult
-place stethoscope on chest and back same as an adult - CORRECT ANSWER - breath
sounds of child (3)
-heart sounds will be similar to the sounds heard in an adult
