D118) QUESTIONS WITH CORRECT
DETAILED ANSWERS 2025
Subjective data - ANSWER- Said by the client (S)
Objective data - ANSWER- Observed by the nurse (O)
Order for assessment (not abdominal) - ANSWER- Inspect, Palpation, Percussion,
Auscultation
Inspection - ANSWER- Critical observation and ALWAYS first in assessment and uses
all senses.
Part of the hand to assess skin temperature - ANSWER- back of the hand (dorsal
aspect)
Deep Palpation
Light Palpation - ANSWER- Deep: 5-8cm (2-3'')
Light: 1 cm
Percussion is performed in the - ANSWER- wrist
Bell of the stethoscope picks up - ANSWER- Low pitched sounds such as heart
murmurs.
Diaphragm of stethoscope picks up - ANSWER- High-pitched respiratory sounds
General Survey - ANSWER- An overall review or first impression a nurse has of a
person's well being
-Appearance
-Body structure/mobility
-Behavior
Comprehensive history - ANSWER- Includes: chief complaint, complete review of
systems, social history and complete family past medical history
Family health history includes - ANSWER- three generations looking for specific
patterns in genetic issues
Comprehensive physical exam includes - ANSWER- Body areas: head, neck, chest
abdomen, genitalia, groin, buttocks, back and extremities.
, Organ systems: constitutional (vital signs, general appearance) eyes, ears, nose, throat,
cardiovascular, gastrointestinal, genitourinary, musculoskeletal, dermatological,
neurological, psychiatric, hematological/lymphatic/immunological.
BMI - ANSWER- measure that can determine if a person is at risk for weight-related
illness.
Head circumference measurement:
Birth-36 mo. - ANSWER- extending a non-stretchable measuring tape around the
broadest part of the child's head.
Accuracy: tape is placed 3 times: right, left side, and at the mid-forehead
Measure the infant's head circumference at birth and at each well-child visit up to age 2
years and then yearly up to 6 years
Measuring head circumference of newborn - ANSWER- 2 cm larger than chest
circumference.
As child ages, chest circumference becomes larger than head circumference.
Chest Measurement - ANSWER- Measured at the nipple line.
Fontanels in a newborn - toddler - ANSWER- Posterior fontanel - triangle shaped;
closes 1-2 mo.
Anterior fontanel - diamond shaped; closes at 9 mo.-2 yrs
Vitals signs are the measurements of - ANSWER- Temperature, pulse, respiration and
blood pressure. Give an immediate picture of person's current state of health and well
being.
Irregular pulse - ANSWER- always count for a full minute and record the rate and
rhythm.
Normal adult heart rate - ANSWER- 60-100 bpm
Normal adult blood pressure - ANSWER- <130/<85
Average Pulse and Blood Pressure in Normal Children - ANSWER- Birth 6mo 1yr 2yr
6yr 8yr 10yr
Pulse 140 130 115 110 103 100 95
Systolic 70 90 90 92 95 100 105
Exam of skin: inspection - ANSWER- Color and uniformity of color, moisture, hair
pattern, rashes, lesions, pallor and edema.
Exam of skin: palpate - ANSWER- temperature, turgor, lesions, edema and texture.