ESTUDYR
NURS 328 ATI 2025 MULTICHOICE ANSWERED EXAM
QUESTIONS WITH DETAILED RATIONALES
1. A nurse is preparing to perform a physical exam on a 10-year-old. Which intervention
should the nurse plan to implement?
a. Allow the child to touch and play with the equipment
b. Play games while performing the physical exam
c. c. Explain how the equipment works using correct medical terminology ✔
d. Discuss the benefits of performing the exam with the cold
Rationale: School-age children want concrete information and enjoy learning
vocabulary; correct terminology respects their cognitive level.
2. When obtaining blood pressure on a school-age child, which action is correct?
a. Position the arm at the level of the umbilicus while the child is sitting in a chair
b. Release cuff pressure at 4–5 mmHg per second
c. Ensure the cuff bladder encircles 50% of the extremity
d. d. Select a cuff width that covers ~40% of the upper arm ✔
Rationale: Proper cuff width (≈40% of arm circumference) ensures accurate readings;
release rate should be ~2–3 mmHg/sec and bladder length should encircle 80–100% of
arm.
3. During the general survey of an adolescent, which finding belongs in the general survey?
a. Deep tendon reflexes 2+ bilaterally
b. Able to read small print at 14 inches
c. Demonstrates fine motor coordination
d. d. Makes good eye contact ✔
Rationale: General survey addresses demeanor, mood, and social interaction (eye
contact), not specific neurologic tests.
4. A nurse inspects a toddler’s skin. Which finding should be reported?
a. Fine hair on lower arms and legs
b. Telangiectatic nevi (stork bite) on neck
c. Mongolian spot across buttocks
d. d. Ecchymotic (bruised) area on the abdomen ✔
Rationale: Bruises in atypical locations (abdomen, torso, face) warrant further
evaluation for possible nonaccidental trauma.
5. When obtaining a temperature on an 18-month-old toddler, the nurse should:
a. Pull pinna up and back before tympanic measurement
b. Insert rectal probe 2.5 cm (1 in)
c. Place oral probe under toddler’s tongue in posterior pocket
,ESTUDYR
d. d. Place the thermometer tip in the center of the axilla against skin ✔
Rationale: Axillary temperature is appropriate for toddlers; tympanic requires pulling
pinna down/back in young children, rectal depth varies (and is used cautiously).
6. A 6-month-old infant — which reflex is expected?
a. Positive extrusion reflex
b. Negative plantar grasp reflex
c. c. Positive Babinski reflex ✔
d. Negative sucking reflex
Rationale: Babinski (toes fan) is normal in infants up to ~12 months; extrusion fades by
~4–6 months; sucking persists.
7. Inspecting an infant’s thorax — expected finding:
a. Primarily thoracic movement during inspiration
b. b. Barrel-shaped chest with AP diameter ≈ lateral (infant) ✔
c. Asymmetrical chest movement
d. Chest circumference twice head circumference
Rationale: Infants often have a relatively rounded (barrel) chest; chest/head ratio
normalizes with growth.
8. For cardiac auscultation in a preschooler, the apical pulse is best heard:
a. Sternal border, 3rd ICS
b. 2nd ICS right of sternum
c. c. Left of midclavicular line at 4th intercostal space ✔
d. 5th ICS left of midclavicular line
Rationale: In young children (<7), the apex/mitral area commonly lies at the 4th ICS left
MCL.
9. Scoliosis screening instruction for a school-age child:
a. “Bend your knees and touch your toes”
b. “Stand facing me with hands on hips”
c. c. “Bend forward with knees straight and arms dangling” ✔
d. “Lie on your stomach with arms extended”
Rationale: Forward bending (Adams test) makes spinal asymmetry/rib hump evident.
10. During an abdominal exam on a preschooler, the nurse should:
a. Ask child to take deep breath and hold while palpating
b. b. Ask child to “help” by placing their hand on nurse’s hand ✔
c. Begin by palpating tender areas
d. Position child with legs and arms extended
Rationale: Involving the preschooler reduces fear/tensing; palpate non-tender areas
first.
,ESTUDYR
11. Anticipatory guidance — expected toddler developmental task:
a. Explain right vs wrong
b. Print letters and numbers
c. c. Separates easily from primary caregiver for short periods ✔
d. Cooperates with simple chores
Rationale: Separation mastery is typical of toddler (≈3 y); moral reasoning and chores
develop later.
12. Best parental approach to toddler tantrums:
a. Restrain the child physically
b. b. Ignore the temper tantrum (after ensuring safety) ✔
c. Tell the child tantrums are unacceptable
d. Distract by offering a game immediately
Rationale: Planned ignoring extinguishes attention-seeking behavior; ensure safety first.
13. Which finding in a 10-month-old should be reported?
a. Unable to imitate animal sounds
b. b. Does not sit steadily without support ✔
c. Cannot turn pages in a book
d. Cannot build tower of 3–4 cubes
Rationale: Independent sitting should be established by ~8 months; lack suggests motor
delay.
14. A hospitalized 18-month-old who sits quietly, sucks thumb, and turns away after mother
leaves — this likely indicates:
a. a. An anxiety/reaction to separation ✔
b. Regression
c. Resentment toward mother
d. Developing autonomy
Rationale: Prolonged hospitalization can provoke anxiety/withdrawal behaviors in
toddlers.
15. Preparing to give deltoid IM vaccine to a preschooler — which is appropriate?
a. Use a 20-gauge needle
b. b. Use ~0.5 in (0.5 inch) needle (e.g., 22–25 gauge) ✔
c. Insert just below the acromion process
d. Insert at 15° angle
Rationale: Use a short (0.5 in) needle for small children, inject about 2 finger-widths (~2
cm) below acromion, at 90°.
16. A mother says, “Teacher says my child squints to see the board.” This statement should:
a. a. Concern the nurse ✔
b. Not be concerning (normal)
, ESTUDYR
c. Indicate behavioral problem only
d. Be ignored; child is fine
Rationale: Squinting suggests visual impairment and warrants referral for eye exam.
17. Put Erikson’s stages in order from birth to adolescence: Autonomy vs Shame (A),
Industry vs Inferiority (B), Trust vs Mistrust (C), Initiative vs Guilt (D), Identity vs Role
Confusion (E). Correct order is:
a. CADBE
b. a. CADBE ✔
c. ABCDE
d. EDCBA
Rationale: Trust (infant) → Autonomy (toddler) → Initiative (preschool) → Industry
(school-age) → Identity (adolescent).
18. A 15-month-old — which finding should be reported?
a. Cannot build tower of 6–7 cubes
b. b. Cannot stand upright without support ✔
c. Cannot jump with both feet
d. Cannot turn a doorknob
Rationale: Independent standing should be present well before 15 months; inability
suggests gross motor delay.
19. Expected finding at 6 months:
a. a. Closed posterior fontanel ✔
b. Uses pincer grasp
c. Lateral incisors erupted
d. Sitting steadily without support
Rationale: Posterior fontanel closes by ~2 months; anterior closes later. (Posterior
should be closed by 6 months.)
20. Teaching parents about tantrums — correct statement:
a. “Leave the room while tantrum happens”
b. b. “Temper tantrums are the toddler’s attempt to gain control” ✔
c. “Get psychological consult immediately”
d. “Tantrums are a learning disability”
Rationale: Tantrums are developmentally typical as toddlers test autonomy and control.
21. Toddler psychosocial stage is characterized by:
a. Imaginary playmates
b. Erikson’s initiative vs guilt
c. Sexual curiosity displays
d. d. Negative behaviors reflecting need for autonomy ✔
Rationale: Toddlerhood centers on autonomy vs shame/doubt; negativism is common.
NURS 328 ATI 2025 MULTICHOICE ANSWERED EXAM
QUESTIONS WITH DETAILED RATIONALES
1. A nurse is preparing to perform a physical exam on a 10-year-old. Which intervention
should the nurse plan to implement?
a. Allow the child to touch and play with the equipment
b. Play games while performing the physical exam
c. c. Explain how the equipment works using correct medical terminology ✔
d. Discuss the benefits of performing the exam with the cold
Rationale: School-age children want concrete information and enjoy learning
vocabulary; correct terminology respects their cognitive level.
2. When obtaining blood pressure on a school-age child, which action is correct?
a. Position the arm at the level of the umbilicus while the child is sitting in a chair
b. Release cuff pressure at 4–5 mmHg per second
c. Ensure the cuff bladder encircles 50% of the extremity
d. d. Select a cuff width that covers ~40% of the upper arm ✔
Rationale: Proper cuff width (≈40% of arm circumference) ensures accurate readings;
release rate should be ~2–3 mmHg/sec and bladder length should encircle 80–100% of
arm.
3. During the general survey of an adolescent, which finding belongs in the general survey?
a. Deep tendon reflexes 2+ bilaterally
b. Able to read small print at 14 inches
c. Demonstrates fine motor coordination
d. d. Makes good eye contact ✔
Rationale: General survey addresses demeanor, mood, and social interaction (eye
contact), not specific neurologic tests.
4. A nurse inspects a toddler’s skin. Which finding should be reported?
a. Fine hair on lower arms and legs
b. Telangiectatic nevi (stork bite) on neck
c. Mongolian spot across buttocks
d. d. Ecchymotic (bruised) area on the abdomen ✔
Rationale: Bruises in atypical locations (abdomen, torso, face) warrant further
evaluation for possible nonaccidental trauma.
5. When obtaining a temperature on an 18-month-old toddler, the nurse should:
a. Pull pinna up and back before tympanic measurement
b. Insert rectal probe 2.5 cm (1 in)
c. Place oral probe under toddler’s tongue in posterior pocket
,ESTUDYR
d. d. Place the thermometer tip in the center of the axilla against skin ✔
Rationale: Axillary temperature is appropriate for toddlers; tympanic requires pulling
pinna down/back in young children, rectal depth varies (and is used cautiously).
6. A 6-month-old infant — which reflex is expected?
a. Positive extrusion reflex
b. Negative plantar grasp reflex
c. c. Positive Babinski reflex ✔
d. Negative sucking reflex
Rationale: Babinski (toes fan) is normal in infants up to ~12 months; extrusion fades by
~4–6 months; sucking persists.
7. Inspecting an infant’s thorax — expected finding:
a. Primarily thoracic movement during inspiration
b. b. Barrel-shaped chest with AP diameter ≈ lateral (infant) ✔
c. Asymmetrical chest movement
d. Chest circumference twice head circumference
Rationale: Infants often have a relatively rounded (barrel) chest; chest/head ratio
normalizes with growth.
8. For cardiac auscultation in a preschooler, the apical pulse is best heard:
a. Sternal border, 3rd ICS
b. 2nd ICS right of sternum
c. c. Left of midclavicular line at 4th intercostal space ✔
d. 5th ICS left of midclavicular line
Rationale: In young children (<7), the apex/mitral area commonly lies at the 4th ICS left
MCL.
9. Scoliosis screening instruction for a school-age child:
a. “Bend your knees and touch your toes”
b. “Stand facing me with hands on hips”
c. c. “Bend forward with knees straight and arms dangling” ✔
d. “Lie on your stomach with arms extended”
Rationale: Forward bending (Adams test) makes spinal asymmetry/rib hump evident.
10. During an abdominal exam on a preschooler, the nurse should:
a. Ask child to take deep breath and hold while palpating
b. b. Ask child to “help” by placing their hand on nurse’s hand ✔
c. Begin by palpating tender areas
d. Position child with legs and arms extended
Rationale: Involving the preschooler reduces fear/tensing; palpate non-tender areas
first.
,ESTUDYR
11. Anticipatory guidance — expected toddler developmental task:
a. Explain right vs wrong
b. Print letters and numbers
c. c. Separates easily from primary caregiver for short periods ✔
d. Cooperates with simple chores
Rationale: Separation mastery is typical of toddler (≈3 y); moral reasoning and chores
develop later.
12. Best parental approach to toddler tantrums:
a. Restrain the child physically
b. b. Ignore the temper tantrum (after ensuring safety) ✔
c. Tell the child tantrums are unacceptable
d. Distract by offering a game immediately
Rationale: Planned ignoring extinguishes attention-seeking behavior; ensure safety first.
13. Which finding in a 10-month-old should be reported?
a. Unable to imitate animal sounds
b. b. Does not sit steadily without support ✔
c. Cannot turn pages in a book
d. Cannot build tower of 3–4 cubes
Rationale: Independent sitting should be established by ~8 months; lack suggests motor
delay.
14. A hospitalized 18-month-old who sits quietly, sucks thumb, and turns away after mother
leaves — this likely indicates:
a. a. An anxiety/reaction to separation ✔
b. Regression
c. Resentment toward mother
d. Developing autonomy
Rationale: Prolonged hospitalization can provoke anxiety/withdrawal behaviors in
toddlers.
15. Preparing to give deltoid IM vaccine to a preschooler — which is appropriate?
a. Use a 20-gauge needle
b. b. Use ~0.5 in (0.5 inch) needle (e.g., 22–25 gauge) ✔
c. Insert just below the acromion process
d. Insert at 15° angle
Rationale: Use a short (0.5 in) needle for small children, inject about 2 finger-widths (~2
cm) below acromion, at 90°.
16. A mother says, “Teacher says my child squints to see the board.” This statement should:
a. a. Concern the nurse ✔
b. Not be concerning (normal)
, ESTUDYR
c. Indicate behavioral problem only
d. Be ignored; child is fine
Rationale: Squinting suggests visual impairment and warrants referral for eye exam.
17. Put Erikson’s stages in order from birth to adolescence: Autonomy vs Shame (A),
Industry vs Inferiority (B), Trust vs Mistrust (C), Initiative vs Guilt (D), Identity vs Role
Confusion (E). Correct order is:
a. CADBE
b. a. CADBE ✔
c. ABCDE
d. EDCBA
Rationale: Trust (infant) → Autonomy (toddler) → Initiative (preschool) → Industry
(school-age) → Identity (adolescent).
18. A 15-month-old — which finding should be reported?
a. Cannot build tower of 6–7 cubes
b. b. Cannot stand upright without support ✔
c. Cannot jump with both feet
d. Cannot turn a doorknob
Rationale: Independent standing should be present well before 15 months; inability
suggests gross motor delay.
19. Expected finding at 6 months:
a. a. Closed posterior fontanel ✔
b. Uses pincer grasp
c. Lateral incisors erupted
d. Sitting steadily without support
Rationale: Posterior fontanel closes by ~2 months; anterior closes later. (Posterior
should be closed by 6 months.)
20. Teaching parents about tantrums — correct statement:
a. “Leave the room while tantrum happens”
b. b. “Temper tantrums are the toddler’s attempt to gain control” ✔
c. “Get psychological consult immediately”
d. “Tantrums are a learning disability”
Rationale: Tantrums are developmentally typical as toddlers test autonomy and control.
21. Toddler psychosocial stage is characterized by:
a. Imaginary playmates
b. Erikson’s initiative vs guilt
c. Sexual curiosity displays
d. d. Negative behaviors reflecting need for autonomy ✔
Rationale: Toddlerhood centers on autonomy vs shame/doubt; negativism is common.
