TEST BANK
PEDIATRIC PRIMARY CARE PRACTICE DUIDLINES
FOR NURSES
,Chapter 1 Obtaining An Initial History
WELL ELABORATED QUESTIONS AND ANSWERS
MULTIPLE CHOICE
1. The Nurse Is Seeing An Adolescent And The Parents In The Clinic For The First Time.
Which Should The Nurse Do First?
a. Introduce Him- Or Herself.
b. Make The Family Comfortable.
c. Give Assurance Of Privacy.
d. Explain The Purpose Of The
Interview.
ANSWER: A
The First Thing That Nurses Must Do Is To Introduce Themselves To The Patient And Family. Parents
And Other Adults Should Be Addressed With Appropriate Titles Unless They Specify A
Preferred Name. Clarification Of The Purpose Of The Interview And The Nurses Role Is The
Second Thing That Should Be Done. During The Initial Part Of The Interview, The Nurse
Should Include General Conversation To Help Make The Family Feel At Ease. The Interview
Also Should Take Place In An Environment As Free Of Distraction As Possible. In Addition,
The Nurse Should Clarify Which Information Will Be Shared With Other Members Of The
Health Care Team And Any Limits To The Confidentiality.
2. Which Is Considered A Block To Effective Communication?
a. Using Silence
b. Using Clichs
c. Directing The Focus
d. Defining The
Problem
ANSWER: B
Using Stereotyped Comments Or Clichs Can Block Effective Communication. After The Nurse Uses
Such Trite Phrases, Parents Often Do Not Respond. Silence Can Be An Effective Interviewing
Tool. Silence Permits The Interviewee To Sort Out Thoughts And Feelings And Search For
Responses To Questions. To Be Effective, The Nurse Must Be Able To Direct The Focus Of
The Interview While Allowing Maximum Freedom Of Expression. By Using Open-Ended
Questions And Guiding Questions, The Nurse Can Obtain The Necessary Information And
Maintain A Relationship With The Family. The Nurse And Parent Must Collaborate And
Define The Problem That Will Be The Focus Of The Nursing Intervention.
3. Which Is The Single Most Important Factor To Consider When Communicating With Children?
a. Presence Of The Childs Parent
b. Childs Physical Condition
c. Childs Developmental Level
, d. Childs Nonverbal
Behaviors
ANSWER: C
The Nurse Must Be Aware Of The Childs Developmental Stage To Engage In Effective
Communication. The Use Of Both Verbal And Nonverbal Communication Should Be
Appropriate To The Developmental Level. Nonverbal Behaviors Vary In Importance Based On
The Childs Developmental Level And Physical Condition. Although The Childs Physical
Condition Is A Consideration, Developmental Level Is Much More Important. The Presence Of
Parents Is Important When Communicating With Young Children But May Be Detrimental
When Speaking With Adolescents.
4. Because Children Younger Than 5 Years Are Egocentric, The Nurse Should Do
Which When Communicating With Them?
a. Focus Communication On The Child.
b. Use Easy Analogies When Possible.
c. Explain Experiences Of Others To The Child.
d. Assure The Child That Communication Is
Private.
ANSWER: A
Because Children Of This Age Are Able To See Things Only In Terms Of Themselves, The Best Approach
Is To Focus Communication Directly On Them. Children Should Be Provided With Information
About What They Can Do And How They Will Feel. With Children Who Are Egocentric,
Analogies, Experiences, And Assurances That Communication Is Private Will Not Be Effective
Because The Child Is Not Capable Of Understanding.
5. The Nurses Approach When Introducing Hospital Equipment To A Preschooler Who Seems
Afraid Should Be Based On Which Principle?
a. The Child May Think The Equipment Is Alive.
b. Explaining The Equipment Will Only Increase The Childs Fear.
c. One Brief Explanation Will Be Enough To Reduce The Childs Fear.
d. The Child Is Too Young To Understand What The Equipment
Does.
ANSWER: A
Young Children Attribute Human Characteristics To Inanimate Objects. They Often Fear That The
Objects May Jump, Bite, Cut, Or Pinch All By Themselves Without Human Direction.
Equipment Should Be Kept Out Of Sight Until Needed. Simple, Concrete Explanations About
What The Equipment Does And How It Will Feel Will Help Alleviate The Childs Fear.
Preschoolers Need Repeated Explanations As Reassurance.
6. When The Nurse Interviews An Adolescent, Which Is Especially Important?
a. Focus The Discussion On The Peer Group.
b. Allow An Opportunity To Express Feelings.
c. Use The Same Type Of Language As The Adolescent.
d. Emphasize That Confidentiality Will Always Be
Maintained. ANSWER: B
Adolescents, Like All Children, Need Opportunities To Express Their Feelings. Often They Interject
,Feelings Into Their Words. The Nurse Must Be Alert To The Words And Feelings Expressed. The Nurse
Should Maintain A Professional Relationship With Adolescents. To Avoid Misunderstanding
Or Misinterpretation Of Words And Phrases Used, The Nurse Should Clarify The Terms Used,
What Information Will Be Shared With Other Members Of The Health Care Team, And Any
Limits To Confidentiality. Although The Peer Group Is Important To This Age Group, The
Interview Should Focus On The Adolescent.
7. The Nurse Is Preparing To Assess A 10-Month-Old Infant. He Is Sitting On His Fathers
Lap And Appears To Be Afraid Of The Nurse And Of What Might Happen Next. Which
Initial Actions By The Nurse Should Be Most Appropriate?
a. Initiate A Game Of Peek-A-Boo.
b. Ask The Infants Father To Place The Infant On The Examination Table.
c. Talk Softly To The Infant While Taking Him From His Father.
d. Undress The Infant While He Is Still Sitting On His Fathers
Lap. ANSWER: A
Peek-A-Boo Is An Excellent Means Of Initiating Communication With Infants While Maintaining A
Safe, Nonthreatening Distance. The Child Will Most Likely Become Upset If Separated From
His Father. As Much Of The Assessment As Possible Should Be Done With The Child On The
Fathers Lap. The Nurse Should Have The Father Undress The Child As Needed During The
Examination.
8. An 8-Year-Old Girl Asks The Nurse How The Blood Pressure Apparatus Works.
The Most Appropriate Nursing Action Is Which?
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. ANSWER: 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 So That The Child
Can Then Observe During The Procedure. The Nurse Should Respond Positively For Requests
For Information About Procedures And Health Information. By Not Responding, The Nurse
May Be Limiting Communication With The Child. The Child Is Not Exhibiting Anxiety In
Asking How The Blood Pressure Apparatus Works, Just Requesting Clarification Of What Will
Occur.
9. The Nurse Is Having Difficulty Communicating With A Hospitalized 6-Year-Old Child.
Which Technique Should Be Most Helpful?
a. Recommend That The Child Keep A Diary.
b. Provide Supplies For The Child To Draw A Picture.
c. Suggest That The Parent Read Fairy Tales To The Child.
d. Ask The Parent If The Child Is Always
Uncommunicative. ANSWER: B
Drawing Is One Of The Most Valuable Forms Of Communication. Childrens Drawings Tell A Great
Deal About Them Because They Are Projections Of The Childrens Inner Self. A Diary Should
Be Difficult For A 6-Year-Old Child, Who Is Most Likely Learning To Read. The Parent
Reading Fairy Tales To The Child Is A Passive Activity Involving The Parent And Child; It
Should Not Facilitate
,Communication With The Nurse. The Child Is In A Stressful Situation And Is Probably
Uncomfortable With Strangers, Not Always Uncommunicative.
10. Which Data Should Be Included In A Health History?
a. Review Of Systems
b. Physical Assessment
c. Growth Measurements
d. Record Of Vital
Signs ANSWER: A
A Review Of Systems Is Done To Elicit Information Concerning Any Potential Health Problems. This
Further Guides The Interview Process. Physical Assessment, Growth Measurements, And A
Record Of Vital Signs Are Components Of The Physical Examination.
11. The Nurse Is Taking A Health History Of An Adolescent. Which Best Describes How
The Chief Complaint Should Be Determined?
a. Request A Detailed Listing Of Symptoms.
b. Ask The Adolescent, Why Did You Come Here Today?
c. Interview The Parent Away From The Adolescent To Determine The Chief Complaint.
d. Use What The Adolescent Says To Determine, In Correct Medical Terminology, What The
Problem Is. ANSWER: B
The Chief Complaint Is The Specific Reason For The Childs Visit To The Clinic, Office, Or Hospital.
Because The Adolescent Is The Focus Of The History, This Is An Appropriate Way To
Determine The Chief Complaint. Requesting A Detailed List Of Symptoms Makes It Difficult To
Determine The Chief Complaint. The Parent And Adolescent May Be Interviewed Separately,
But The Nurse Should Determine The Reason The Adolescent Is Seeking Attention At This
Time. The Chief Complaint Is Usually Written In The Words That The Parent Or Adolescent
Uses To Describe The Reason For Seeking Help.
12. The Nurse Is Interviewing The Mother Of An Infant. The Mother Reports, I Had A
Difficult Delivery, And My Baby Was Born Prematurely. This Information Should Be
Recorded Under Which Heading?
a. History
b. Present Illness
c. Chief Complaint
d. Review Of
Systems ANSWER: A
The History Refers To Information That Relates To Previous Aspects Of The Childs Health, Not To The
Current Problem. The Difficult Delivery And Prematurity Are Important Parts Of The Infants
History. The History Of The Present Illness Is A Narrative Of The Chief Complaint From Its
Earliest Onset Through Its Progression To The Present. Unless The Chief Complaint Is Directly
Related To The Prematurity, This Information Is Not Included In The History Of The Present
Illness. The Chief Complaint Is The Specific Reason For The Childs Visit To The Clinic, Office,
Or Hospital. It Should Not Include The Birth Information. The Review Of Systems Is A Specific
Review Of Each Body System. It Does Not Include The Premature Birth But Might Include
Sequelae Such As Pulmonary Dysfunction.
13. Where In The Health History Does A Record Of Immunizations Belong?
, a. History
b. Present Illness
c. Review Of Systems
d. Physical
Assessment ANSWER: A
The History Contains Information Relatingxto All Previous Aspects Of The Childs Health Status. The
Immunizations Arexappropriately Included In The History. Thexpresent Illness, Review Of
Systems, An D Physical Assessment Arexnot Appropriate Places To Record The Immunization
Status.
14. The Nurse Is Taking A Sexual History On An Adolescent Girl. Which Is The Best Way To
Determine W Hether She Is Sexually Active?
a. Ask Her, Are You Sexually Active?
b. Ask Her, Are You Having Sex With Anyone?
c. Ask Her, Are You Having Sex With A Boyfriend?
d. Ask Both The Girl And Her Parent If She Is Sexually
Active. ANSWER: B
Asking The Adolescent Girl If She Is Having Sex With Anyone Is A Direct Question That Is Well
Understood. Thexphrase Sexually Active Is Broadly Defined And May Not Provide Specific
Informatio N For The Nurse To Provide Necessary Care. The Word Anyone Is Preferred To
Using Gender-
Specific Terms Such As Boyfriend Or Girlfriend. Using Gender-
Neutral Terms Is Inclusive And Conveys Acceptance To The Adolescent. Questioning About
Sexual Acti Vity Should Occur When The Adolescent Is Alone.
15. When Doingxa Nutritional Assessment On A Hispanic Family, The Nurse Learns That Their
Diet Con Sists Mainly Of Vegetables, Legumes, And Starches. The Nurse Should Recognize That
This Diet Is Whic H?
a. Lacking In Protein
b. Indicating They Live Inxpoverty
c. Providing Sufficient Amino Acids
d. Needingxenrichment With Meat And
Milk ANSWER: C
A Diet That Contains Vegetables, Legumes, And Starches Mayprovide Sufficient Essential Amino
Acids Even Though The Actual Amountxof Meat Or Dairy Protein Is Low. Combinations Of
Foods Contai N The Essential Amino Acids Necessary For Growth. Many Cultures Use Diets That
Containxthis Combina Tion Of Foods. It Is Not Indicative Of Poverty. A Dietary Assessment
Should Be Done, But Many Vegeta Rian Diets Are Sufficient For Growth.
16. Which Parameter Correlates Best With Measurements Of Total Muscle Mass?
a. Height
b. Weight
c. Skinfold Thickness
d. Upper Arm
Circumference ANSWER: D
,Upper Arm Circumference Is Correlated With Measurements Of Total Muscle Mass.
Musclexserves As The Bodys Major Protein Reserve And Is Considered An Index Of The Bodys
Protein Stores. Height Is R Eflective Of Past Nutritional Status. Weight Is Indicative Of Current
Nutritional Status. Skinfold Thick Ness Is A Measurement Of The Bodys Fat Content.
17. The Nurse Is Preparing To Perform A Physical Assessment On A 10-Year-
Old Girl. Thexnurse Gives Her The Option Of Her Mother Staying In The Room Or Leaving.
This Acti On Should Be Considered Which?
a. Appropriate Because Of Childs Age
b. Appropriate, But The Mother May Be Uncomfortable
c. Inappropriate Because Of Childs Age
d. Inappropriate Because Child Is Same Sex As
Mother ANSWER: A
It Is Appropriate To Give Older School-Age Childrenxthe Option Of Having The Parent Present Or Not.
During The Examination, The Nurse Should Respect The Childs Needxfor Privacy. Children
Who Are 1 0 Years Old Are Minors, And Parents Are Responsible For Health Care Decisions.
The Mother Of A 10
-Year-
Old Child Would Not Be Uncomfortable. The Child Should Help Determine Who Is Present
Duringxth E Examination.
18. With The National Center For Health Statistics Criteria, Whichxbody Mass Index
(BMI)For- Age Percentiles Should Indicate The Patient Is At Risk For Being Overweight?
a. 10th Percentile
b. 75th Percentile
c. 85th Percentile
d. 95th
Percentile ANSWER:
C
Children Who Have BMI-For-Age Greater Than Or Equal To The 85thxpercentile And Less Thanxthe
95th Percentile Are At Risk For Being Overweight. Children Who Are Greater Than Or Equal
To The 9 5th Percentile Are Considered Overweight. Children Whosexbmixis Between The
10th And 75th Pe Rcentiles Are Within Normal Limits.
19. Rectal Temperatures Are Indicated In Which Situation?
a. In Thexnewborn Period
b. Whenever Accuracy Is Essential
c. Rectal Temperatures Arexnever Indicated
d. When Rapid Temperature Changes Are
Occurringx ANSWER: B
Rectal Temperatures Are Recommended When Definitive Measurements Are Necessary In Infants
Older Than Age 1 Month. Rectal Temperatures Are Not Done In The Newborn Period To Avoid
Trauma To The Rectal Mucosa. Rectal Temperature Is An Intrusive Procedure That Should Be
Avoided Whenever Possible.
20. What Is The Earliest Age At Which A Satisfactory Radial Pulse Can Bextaken In Children?
a. 1 Year
b. 2 Years
, c. 3 Years
d. 6
Years
ANSWER: B
Satisfactory Radial Pulses Can Be Taken In Children Older Than 2 Years. In Infants And Young
Children, The Apical Pulse Is Morexreliable.
21. The Nurse Needs To Take The Blood Pressure Of A Small Child. Of The Cuffs Available,
Onexis Too La Rge And One Is Too Small. The Best Nursing Action Is Which?
a. Use The Small Cuff.
b. Use The Large Cuff.
c. Use Either Cuff Using The Palpation Method.
d. Wait To Take The Blood Pressure Until A Proper Cuff Can Be
Located. ANSWER: B
If Blood Pressure Measurement Is Indicated And The Appropriate Size Cuff Is Not Available, The Next
Larger Size Is Used. The Nursexrecognizes That This May Be A Falsely Low Blood Pressure.
Using Thexs Mall Cuff Will Give An Incorrectly High Reading. The Palpation Method Will Not
Improvexthe Inaccur Acy Inherent In The Cuff.
22. Where Is The Best Place To Observe For Thexpresence Of Petechiae In Dark-Skinned Individuals?
a. Face
b. Buttocks
c. Oral Mucosa
d. Palms And
Soles ANSWER: C
Petechiae, Small Distinct Pinpoint Hemorrhages, Are Difficult To Seexin Dark-Skinned Individuals
Unless They Are Inxthe Mouth Or Conjunctiva.
23. During A Routine Health Assessment, The Nurse Notes That An 8-
Month- Old Infant Has A Significant Head Lag. Which Is Thexmost
Appropriatexaction?
a. Recheck Head Control At Next Visit.
b. Teach The Parents Appropriate Exercises.
c. Schedule Thexchild For Further Evaluation.
d. Refer The Child For Further Evaluation If The Anterior Fontanel Is Still
Open. ANSWER: C
Significant Head Lag After Age 6 Months Strongly Indicates Cerebral Injury And Is Referred For
Further Evaluation. Head Control Is Part Of Normal Development. Exercises Will Not
Bexeffective. Th E Lack Of Achievement Of This Developmental Milestone Must Be Evaluated.
24. The Nurse Has Just Started Assessing A Young Child Who Is Febrile And Appears Ill.
There Is H Yperextension Of The Childs Head (Opisthotonos) With Pain On Flexion. Which
Is Thexmost Appr Opriate Action?
a. Ask The Parent When Thexneck Was Injured.
b. Refer For Immediate Medical Evaluation.
c. Continue Assessment To Determine The Cause Of Thexneck Pain.
, d. Record Head Lag On The Assessment Record And Continue The Assessment Of
The Child. ANSWER: B
Hyperextension Of The Childs Head With Pain On Flexion Is Indicative Of Meningeal Irritation And
Needs Immediate Evaluation. No Indication Of Injury Is Present. This Situation Is Not
Descriptive O F Head Lag.
25. During A Funduscopic Examination Of A School-
Age Child, The Nurse Notes A Brilliant, Uniform Red Reflex In Both Eyes. The Nurse Should
Recognize That This Is Which?
a. A Normal Finding
b. A Sign Of A Possible Visual Defect And A Need For Vision Screening
c. An Abnormal Finding Requiring Referral To An Ophthalmologist
d. A Sign Of Small Hemorrhages, Which Usually Resolve
Spontaneously ANSWER: A
A Brilliant, Uniform Redxreflex Is An Important Normal Finding. It Rules Out Many Serious Defects Of
The Cornea, Aqueous Chamber, Lens, And Vitreous Chamber.
26. Which Explains The Importance Of Detecting Strabismus In Young Children?
a. Color Vision Deficit May Result.
b. Amblyopia, Axtype Of Blindness, May Result.
c. Epicanthal Folds May Develop In The Affected Eye.
d. Corneal Light Reflexes May Fall Symmetrically Within Each
Pupil. ANSWER: B
Bythe Age Of 3 To 4 Months, Infants Are Able To Fixate On One Visual Field With Both Eyes
Simultaneously. In Strabismus, Or Cross-
Eye, One Eyexdeviates From The Point Of Fixation. If Misalignment Is Constant, The Weak Eye
Become S Lazy, And The Brain Eventually Suppresses The Image Produced From That Eye. If
Strabismus Is Not D Etected And Corrected By Age 4 To 6 Years, Blindness From Disuse,
Known As Amblyopia, May Occur. Color Vision Is Not The Only Concern. Epicanthal Folds Are
Not Related To Amblyopia. In Childrenxwith Strabismus, The Corneal Light Reflex Will Not Be
Symmetric For Each Eye.
27. Which Is The Most Frequently Used Test For Measuring Visual Acuity?
a. Snellen Letter Chart
b. Ishihara Vision Test
c. Allen Picture Card Test
d. Denver Eye
Screeningxtest ANSWER: A
The Snellen Letter Chart, Which Consists Of Lines Of Letters Of Decreasing Size, Is The Most
Frequently Used Test For Visual Acuity. The Ishihara Vision Test Is Used For Color Vision.
Thexallen P Icture Card Test And Denver Eye Screening Test Involve Single Cards For Children
Ages 2 Years And Old Er Who Are Unable To Usexthe Snellen Letter Chart.
28. The Nurse Is Testing An Infants Visual Acuity. By Which Age Should The Infant Be Able To
Fix On A Nd Follow A Target?
a. 1 Month
, b. 1 To 2 Months
c. 3 To 4 Months
d. 6
Months
ANSWER: C
Visual Fixation And Ability To Follow A Target Should Be Present By Ages 3 To 4 Months. One To 2
Months Is Tooxyoung For This Developmental Milestone. If An Infant Is Not Able To Fix And
Follow B Y 6 Months, Further Ophthalmologic Evaluation Is Needed.
29. During An Otoscopic Examination On An Infant, In Which Direction Is Thexpinna Pulled?
a. Up And Back
b. Up And Forward
c. Down And Back
d. Down And
Forward ANSWER: C
In Infants And Toddlers, The Ear Canal Is Curved Upward. To Visualize The Ear Canal, It Is Necessary
To Pull The Pinna Down And Back To The 6 To 9 Oclockxrangexto Straighten The Canal. In
Children Older Than Age 3 Yearsxandxadults, The Canal Curves Downward And Forward. The
Pinna Is Pulled Up Andxb Ack To The 10 Oclock Position. Up And Forward And Down And
Forward Are Positions That Do Not Facil Itate Visualization Of The Ear Canal.
PEDIATRIC PRIMARY CARE PRACTICE DUIDLINES
FOR NURSES
,Chapter 1 Obtaining An Initial History
WELL ELABORATED QUESTIONS AND ANSWERS
MULTIPLE CHOICE
1. The Nurse Is Seeing An Adolescent And The Parents In The Clinic For The First Time.
Which Should The Nurse Do First?
a. Introduce Him- Or Herself.
b. Make The Family Comfortable.
c. Give Assurance Of Privacy.
d. Explain The Purpose Of The
Interview.
ANSWER: A
The First Thing That Nurses Must Do Is To Introduce Themselves To The Patient And Family. Parents
And Other Adults Should Be Addressed With Appropriate Titles Unless They Specify A
Preferred Name. Clarification Of The Purpose Of The Interview And The Nurses Role Is The
Second Thing That Should Be Done. During The Initial Part Of The Interview, The Nurse
Should Include General Conversation To Help Make The Family Feel At Ease. The Interview
Also Should Take Place In An Environment As Free Of Distraction As Possible. In Addition,
The Nurse Should Clarify Which Information Will Be Shared With Other Members Of The
Health Care Team And Any Limits To The Confidentiality.
2. Which Is Considered A Block To Effective Communication?
a. Using Silence
b. Using Clichs
c. Directing The Focus
d. Defining The
Problem
ANSWER: B
Using Stereotyped Comments Or Clichs Can Block Effective Communication. After The Nurse Uses
Such Trite Phrases, Parents Often Do Not Respond. Silence Can Be An Effective Interviewing
Tool. Silence Permits The Interviewee To Sort Out Thoughts And Feelings And Search For
Responses To Questions. To Be Effective, The Nurse Must Be Able To Direct The Focus Of
The Interview While Allowing Maximum Freedom Of Expression. By Using Open-Ended
Questions And Guiding Questions, The Nurse Can Obtain The Necessary Information And
Maintain A Relationship With The Family. The Nurse And Parent Must Collaborate And
Define The Problem That Will Be The Focus Of The Nursing Intervention.
3. Which Is The Single Most Important Factor To Consider When Communicating With Children?
a. Presence Of The Childs Parent
b. Childs Physical Condition
c. Childs Developmental Level
, d. Childs Nonverbal
Behaviors
ANSWER: C
The Nurse Must Be Aware Of The Childs Developmental Stage To Engage In Effective
Communication. The Use Of Both Verbal And Nonverbal Communication Should Be
Appropriate To The Developmental Level. Nonverbal Behaviors Vary In Importance Based On
The Childs Developmental Level And Physical Condition. Although The Childs Physical
Condition Is A Consideration, Developmental Level Is Much More Important. The Presence Of
Parents Is Important When Communicating With Young Children But May Be Detrimental
When Speaking With Adolescents.
4. Because Children Younger Than 5 Years Are Egocentric, The Nurse Should Do
Which When Communicating With Them?
a. Focus Communication On The Child.
b. Use Easy Analogies When Possible.
c. Explain Experiences Of Others To The Child.
d. Assure The Child That Communication Is
Private.
ANSWER: A
Because Children Of This Age Are Able To See Things Only In Terms Of Themselves, The Best Approach
Is To Focus Communication Directly On Them. Children Should Be Provided With Information
About What They Can Do And How They Will Feel. With Children Who Are Egocentric,
Analogies, Experiences, And Assurances That Communication Is Private Will Not Be Effective
Because The Child Is Not Capable Of Understanding.
5. The Nurses Approach When Introducing Hospital Equipment To A Preschooler Who Seems
Afraid Should Be Based On Which Principle?
a. The Child May Think The Equipment Is Alive.
b. Explaining The Equipment Will Only Increase The Childs Fear.
c. One Brief Explanation Will Be Enough To Reduce The Childs Fear.
d. The Child Is Too Young To Understand What The Equipment
Does.
ANSWER: A
Young Children Attribute Human Characteristics To Inanimate Objects. They Often Fear That The
Objects May Jump, Bite, Cut, Or Pinch All By Themselves Without Human Direction.
Equipment Should Be Kept Out Of Sight Until Needed. Simple, Concrete Explanations About
What The Equipment Does And How It Will Feel Will Help Alleviate The Childs Fear.
Preschoolers Need Repeated Explanations As Reassurance.
6. When The Nurse Interviews An Adolescent, Which Is Especially Important?
a. Focus The Discussion On The Peer Group.
b. Allow An Opportunity To Express Feelings.
c. Use The Same Type Of Language As The Adolescent.
d. Emphasize That Confidentiality Will Always Be
Maintained. ANSWER: B
Adolescents, Like All Children, Need Opportunities To Express Their Feelings. Often They Interject
,Feelings Into Their Words. The Nurse Must Be Alert To The Words And Feelings Expressed. The Nurse
Should Maintain A Professional Relationship With Adolescents. To Avoid Misunderstanding
Or Misinterpretation Of Words And Phrases Used, The Nurse Should Clarify The Terms Used,
What Information Will Be Shared With Other Members Of The Health Care Team, And Any
Limits To Confidentiality. Although The Peer Group Is Important To This Age Group, The
Interview Should Focus On The Adolescent.
7. The Nurse Is Preparing To Assess A 10-Month-Old Infant. He Is Sitting On His Fathers
Lap And Appears To Be Afraid Of The Nurse And Of What Might Happen Next. Which
Initial Actions By The Nurse Should Be Most Appropriate?
a. Initiate A Game Of Peek-A-Boo.
b. Ask The Infants Father To Place The Infant On The Examination Table.
c. Talk Softly To The Infant While Taking Him From His Father.
d. Undress The Infant While He Is Still Sitting On His Fathers
Lap. ANSWER: A
Peek-A-Boo Is An Excellent Means Of Initiating Communication With Infants While Maintaining A
Safe, Nonthreatening Distance. The Child Will Most Likely Become Upset If Separated From
His Father. As Much Of The Assessment As Possible Should Be Done With The Child On The
Fathers Lap. The Nurse Should Have The Father Undress The Child As Needed During The
Examination.
8. An 8-Year-Old Girl Asks The Nurse How The Blood Pressure Apparatus Works.
The Most Appropriate Nursing Action Is Which?
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. ANSWER: 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 So That The Child
Can Then Observe During The Procedure. The Nurse Should Respond Positively For Requests
For Information About Procedures And Health Information. By Not Responding, The Nurse
May Be Limiting Communication With The Child. The Child Is Not Exhibiting Anxiety In
Asking How The Blood Pressure Apparatus Works, Just Requesting Clarification Of What Will
Occur.
9. The Nurse Is Having Difficulty Communicating With A Hospitalized 6-Year-Old Child.
Which Technique Should Be Most Helpful?
a. Recommend That The Child Keep A Diary.
b. Provide Supplies For The Child To Draw A Picture.
c. Suggest That The Parent Read Fairy Tales To The Child.
d. Ask The Parent If The Child Is Always
Uncommunicative. ANSWER: B
Drawing Is One Of The Most Valuable Forms Of Communication. Childrens Drawings Tell A Great
Deal About Them Because They Are Projections Of The Childrens Inner Self. A Diary Should
Be Difficult For A 6-Year-Old Child, Who Is Most Likely Learning To Read. The Parent
Reading Fairy Tales To The Child Is A Passive Activity Involving The Parent And Child; It
Should Not Facilitate
,Communication With The Nurse. The Child Is In A Stressful Situation And Is Probably
Uncomfortable With Strangers, Not Always Uncommunicative.
10. Which Data Should Be Included In A Health History?
a. Review Of Systems
b. Physical Assessment
c. Growth Measurements
d. Record Of Vital
Signs ANSWER: A
A Review Of Systems Is Done To Elicit Information Concerning Any Potential Health Problems. This
Further Guides The Interview Process. Physical Assessment, Growth Measurements, And A
Record Of Vital Signs Are Components Of The Physical Examination.
11. The Nurse Is Taking A Health History Of An Adolescent. Which Best Describes How
The Chief Complaint Should Be Determined?
a. Request A Detailed Listing Of Symptoms.
b. Ask The Adolescent, Why Did You Come Here Today?
c. Interview The Parent Away From The Adolescent To Determine The Chief Complaint.
d. Use What The Adolescent Says To Determine, In Correct Medical Terminology, What The
Problem Is. ANSWER: B
The Chief Complaint Is The Specific Reason For The Childs Visit To The Clinic, Office, Or Hospital.
Because The Adolescent Is The Focus Of The History, This Is An Appropriate Way To
Determine The Chief Complaint. Requesting A Detailed List Of Symptoms Makes It Difficult To
Determine The Chief Complaint. The Parent And Adolescent May Be Interviewed Separately,
But The Nurse Should Determine The Reason The Adolescent Is Seeking Attention At This
Time. The Chief Complaint Is Usually Written In The Words That The Parent Or Adolescent
Uses To Describe The Reason For Seeking Help.
12. The Nurse Is Interviewing The Mother Of An Infant. The Mother Reports, I Had A
Difficult Delivery, And My Baby Was Born Prematurely. This Information Should Be
Recorded Under Which Heading?
a. History
b. Present Illness
c. Chief Complaint
d. Review Of
Systems ANSWER: A
The History Refers To Information That Relates To Previous Aspects Of The Childs Health, Not To The
Current Problem. The Difficult Delivery And Prematurity Are Important Parts Of The Infants
History. The History Of The Present Illness Is A Narrative Of The Chief Complaint From Its
Earliest Onset Through Its Progression To The Present. Unless The Chief Complaint Is Directly
Related To The Prematurity, This Information Is Not Included In The History Of The Present
Illness. The Chief Complaint Is The Specific Reason For The Childs Visit To The Clinic, Office,
Or Hospital. It Should Not Include The Birth Information. The Review Of Systems Is A Specific
Review Of Each Body System. It Does Not Include The Premature Birth But Might Include
Sequelae Such As Pulmonary Dysfunction.
13. Where In The Health History Does A Record Of Immunizations Belong?
, a. History
b. Present Illness
c. Review Of Systems
d. Physical
Assessment ANSWER: A
The History Contains Information Relatingxto All Previous Aspects Of The Childs Health Status. The
Immunizations Arexappropriately Included In The History. Thexpresent Illness, Review Of
Systems, An D Physical Assessment Arexnot Appropriate Places To Record The Immunization
Status.
14. The Nurse Is Taking A Sexual History On An Adolescent Girl. Which Is The Best Way To
Determine W Hether She Is Sexually Active?
a. Ask Her, Are You Sexually Active?
b. Ask Her, Are You Having Sex With Anyone?
c. Ask Her, Are You Having Sex With A Boyfriend?
d. Ask Both The Girl And Her Parent If She Is Sexually
Active. ANSWER: B
Asking The Adolescent Girl If She Is Having Sex With Anyone Is A Direct Question That Is Well
Understood. Thexphrase Sexually Active Is Broadly Defined And May Not Provide Specific
Informatio N For The Nurse To Provide Necessary Care. The Word Anyone Is Preferred To
Using Gender-
Specific Terms Such As Boyfriend Or Girlfriend. Using Gender-
Neutral Terms Is Inclusive And Conveys Acceptance To The Adolescent. Questioning About
Sexual Acti Vity Should Occur When The Adolescent Is Alone.
15. When Doingxa Nutritional Assessment On A Hispanic Family, The Nurse Learns That Their
Diet Con Sists Mainly Of Vegetables, Legumes, And Starches. The Nurse Should Recognize That
This Diet Is Whic H?
a. Lacking In Protein
b. Indicating They Live Inxpoverty
c. Providing Sufficient Amino Acids
d. Needingxenrichment With Meat And
Milk ANSWER: C
A Diet That Contains Vegetables, Legumes, And Starches Mayprovide Sufficient Essential Amino
Acids Even Though The Actual Amountxof Meat Or Dairy Protein Is Low. Combinations Of
Foods Contai N The Essential Amino Acids Necessary For Growth. Many Cultures Use Diets That
Containxthis Combina Tion Of Foods. It Is Not Indicative Of Poverty. A Dietary Assessment
Should Be Done, But Many Vegeta Rian Diets Are Sufficient For Growth.
16. Which Parameter Correlates Best With Measurements Of Total Muscle Mass?
a. Height
b. Weight
c. Skinfold Thickness
d. Upper Arm
Circumference ANSWER: D
,Upper Arm Circumference Is Correlated With Measurements Of Total Muscle Mass.
Musclexserves As The Bodys Major Protein Reserve And Is Considered An Index Of The Bodys
Protein Stores. Height Is R Eflective Of Past Nutritional Status. Weight Is Indicative Of Current
Nutritional Status. Skinfold Thick Ness Is A Measurement Of The Bodys Fat Content.
17. The Nurse Is Preparing To Perform A Physical Assessment On A 10-Year-
Old Girl. Thexnurse Gives Her The Option Of Her Mother Staying In The Room Or Leaving.
This Acti On Should Be Considered Which?
a. Appropriate Because Of Childs Age
b. Appropriate, But The Mother May Be Uncomfortable
c. Inappropriate Because Of Childs Age
d. Inappropriate Because Child Is Same Sex As
Mother ANSWER: A
It Is Appropriate To Give Older School-Age Childrenxthe Option Of Having The Parent Present Or Not.
During The Examination, The Nurse Should Respect The Childs Needxfor Privacy. Children
Who Are 1 0 Years Old Are Minors, And Parents Are Responsible For Health Care Decisions.
The Mother Of A 10
-Year-
Old Child Would Not Be Uncomfortable. The Child Should Help Determine Who Is Present
Duringxth E Examination.
18. With The National Center For Health Statistics Criteria, Whichxbody Mass Index
(BMI)For- Age Percentiles Should Indicate The Patient Is At Risk For Being Overweight?
a. 10th Percentile
b. 75th Percentile
c. 85th Percentile
d. 95th
Percentile ANSWER:
C
Children Who Have BMI-For-Age Greater Than Or Equal To The 85thxpercentile And Less Thanxthe
95th Percentile Are At Risk For Being Overweight. Children Who Are Greater Than Or Equal
To The 9 5th Percentile Are Considered Overweight. Children Whosexbmixis Between The
10th And 75th Pe Rcentiles Are Within Normal Limits.
19. Rectal Temperatures Are Indicated In Which Situation?
a. In Thexnewborn Period
b. Whenever Accuracy Is Essential
c. Rectal Temperatures Arexnever Indicated
d. When Rapid Temperature Changes Are
Occurringx ANSWER: B
Rectal Temperatures Are Recommended When Definitive Measurements Are Necessary In Infants
Older Than Age 1 Month. Rectal Temperatures Are Not Done In The Newborn Period To Avoid
Trauma To The Rectal Mucosa. Rectal Temperature Is An Intrusive Procedure That Should Be
Avoided Whenever Possible.
20. What Is The Earliest Age At Which A Satisfactory Radial Pulse Can Bextaken In Children?
a. 1 Year
b. 2 Years
, c. 3 Years
d. 6
Years
ANSWER: B
Satisfactory Radial Pulses Can Be Taken In Children Older Than 2 Years. In Infants And Young
Children, The Apical Pulse Is Morexreliable.
21. The Nurse Needs To Take The Blood Pressure Of A Small Child. Of The Cuffs Available,
Onexis Too La Rge And One Is Too Small. The Best Nursing Action Is Which?
a. Use The Small Cuff.
b. Use The Large Cuff.
c. Use Either Cuff Using The Palpation Method.
d. Wait To Take The Blood Pressure Until A Proper Cuff Can Be
Located. ANSWER: B
If Blood Pressure Measurement Is Indicated And The Appropriate Size Cuff Is Not Available, The Next
Larger Size Is Used. The Nursexrecognizes That This May Be A Falsely Low Blood Pressure.
Using Thexs Mall Cuff Will Give An Incorrectly High Reading. The Palpation Method Will Not
Improvexthe Inaccur Acy Inherent In The Cuff.
22. Where Is The Best Place To Observe For Thexpresence Of Petechiae In Dark-Skinned Individuals?
a. Face
b. Buttocks
c. Oral Mucosa
d. Palms And
Soles ANSWER: C
Petechiae, Small Distinct Pinpoint Hemorrhages, Are Difficult To Seexin Dark-Skinned Individuals
Unless They Are Inxthe Mouth Or Conjunctiva.
23. During A Routine Health Assessment, The Nurse Notes That An 8-
Month- Old Infant Has A Significant Head Lag. Which Is Thexmost
Appropriatexaction?
a. Recheck Head Control At Next Visit.
b. Teach The Parents Appropriate Exercises.
c. Schedule Thexchild For Further Evaluation.
d. Refer The Child For Further Evaluation If The Anterior Fontanel Is Still
Open. ANSWER: C
Significant Head Lag After Age 6 Months Strongly Indicates Cerebral Injury And Is Referred For
Further Evaluation. Head Control Is Part Of Normal Development. Exercises Will Not
Bexeffective. Th E Lack Of Achievement Of This Developmental Milestone Must Be Evaluated.
24. The Nurse Has Just Started Assessing A Young Child Who Is Febrile And Appears Ill.
There Is H Yperextension Of The Childs Head (Opisthotonos) With Pain On Flexion. Which
Is Thexmost Appr Opriate Action?
a. Ask The Parent When Thexneck Was Injured.
b. Refer For Immediate Medical Evaluation.
c. Continue Assessment To Determine The Cause Of Thexneck Pain.
, d. Record Head Lag On The Assessment Record And Continue The Assessment Of
The Child. ANSWER: B
Hyperextension Of The Childs Head With Pain On Flexion Is Indicative Of Meningeal Irritation And
Needs Immediate Evaluation. No Indication Of Injury Is Present. This Situation Is Not
Descriptive O F Head Lag.
25. During A Funduscopic Examination Of A School-
Age Child, The Nurse Notes A Brilliant, Uniform Red Reflex In Both Eyes. The Nurse Should
Recognize That This Is Which?
a. A Normal Finding
b. A Sign Of A Possible Visual Defect And A Need For Vision Screening
c. An Abnormal Finding Requiring Referral To An Ophthalmologist
d. A Sign Of Small Hemorrhages, Which Usually Resolve
Spontaneously ANSWER: A
A Brilliant, Uniform Redxreflex Is An Important Normal Finding. It Rules Out Many Serious Defects Of
The Cornea, Aqueous Chamber, Lens, And Vitreous Chamber.
26. Which Explains The Importance Of Detecting Strabismus In Young Children?
a. Color Vision Deficit May Result.
b. Amblyopia, Axtype Of Blindness, May Result.
c. Epicanthal Folds May Develop In The Affected Eye.
d. Corneal Light Reflexes May Fall Symmetrically Within Each
Pupil. ANSWER: B
Bythe Age Of 3 To 4 Months, Infants Are Able To Fixate On One Visual Field With Both Eyes
Simultaneously. In Strabismus, Or Cross-
Eye, One Eyexdeviates From The Point Of Fixation. If Misalignment Is Constant, The Weak Eye
Become S Lazy, And The Brain Eventually Suppresses The Image Produced From That Eye. If
Strabismus Is Not D Etected And Corrected By Age 4 To 6 Years, Blindness From Disuse,
Known As Amblyopia, May Occur. Color Vision Is Not The Only Concern. Epicanthal Folds Are
Not Related To Amblyopia. In Childrenxwith Strabismus, The Corneal Light Reflex Will Not Be
Symmetric For Each Eye.
27. Which Is The Most Frequently Used Test For Measuring Visual Acuity?
a. Snellen Letter Chart
b. Ishihara Vision Test
c. Allen Picture Card Test
d. Denver Eye
Screeningxtest ANSWER: A
The Snellen Letter Chart, Which Consists Of Lines Of Letters Of Decreasing Size, Is The Most
Frequently Used Test For Visual Acuity. The Ishihara Vision Test Is Used For Color Vision.
Thexallen P Icture Card Test And Denver Eye Screening Test Involve Single Cards For Children
Ages 2 Years And Old Er Who Are Unable To Usexthe Snellen Letter Chart.
28. The Nurse Is Testing An Infants Visual Acuity. By Which Age Should The Infant Be Able To
Fix On A Nd Follow A Target?
a. 1 Month
, b. 1 To 2 Months
c. 3 To 4 Months
d. 6
Months
ANSWER: C
Visual Fixation And Ability To Follow A Target Should Be Present By Ages 3 To 4 Months. One To 2
Months Is Tooxyoung For This Developmental Milestone. If An Infant Is Not Able To Fix And
Follow B Y 6 Months, Further Ophthalmologic Evaluation Is Needed.
29. During An Otoscopic Examination On An Infant, In Which Direction Is Thexpinna Pulled?
a. Up And Back
b. Up And Forward
c. Down And Back
d. Down And
Forward ANSWER: C
In Infants And Toddlers, The Ear Canal Is Curved Upward. To Visualize The Ear Canal, It Is Necessary
To Pull The Pinna Down And Back To The 6 To 9 Oclockxrangexto Straighten The Canal. In
Children Older Than Age 3 Yearsxandxadults, The Canal Curves Downward And Forward. The
Pinna Is Pulled Up Andxb Ack To The 10 Oclock Position. Up And Forward And Down And
Forward Are Positions That Do Not Facil Itate Visualization Of The Ear Canal.
