NURS 3511 Week 2 Exam Questions with Correct Answers Latest Update 2025-2026
What are the three components of the Paediatric Assessment Triangle?
A) Appearance, breathing, circulation
B) Heart rate, respiratory rate, oxygen saturation
C) Blood pressure, temperature, skin color
D) Reflexes, muscle strength, pupil reaction - Answers A) Appearance, breathing, circulation
The Pediatric Assessment Triangle is conducted as a(n):
A) Hands-on physical examination
B) Cross-the-room assessment
C) Laboratory test for pediatric patients
D) Detailed neurological evaluation - Answers B) Cross-the-room assessment
Look and listen
What is the primary purpose of the Paediatric Assessment Triangle?
A) To determine if a child needs immediate intervention
B) To establish a definitive diagnosis
C) To measure vital signs accurately
D) To perform a detailed cardiovascular examination - Answers A) To determine if a child needs
immediate intervention
Which of the following is NOT a component of the "general appearance" assessment?
A) Tone
B) Interactiveness
C) Blood pressure
D) Consolability - Answers C) Blood pressure
Match each aspect of general appearance to the correct description.
1. Tone
2. Interactiveness
,3. Consolability
4. Look/gaze
5. Speech/cry
A) Appears alert and engaged with clinician or caregiver, interacts with people and environment,
reaches for toys, objects
B) Makes eye contact with clinician, tracks visually
C) Moves spontaneously, resists examination, sits/stands (age appropriate)
D) Has strong cry, uses age-appropriate speech
E) Stops crying when held and comforted by caregiver, has differential response to caregiver vs
examiner - Answers 1. C
2. A
3. E
4. B
5. D
Which of the following describes normal spontaneous breathing?
A) Increased work of breathing
B) Effortless respirations
C) Tripoding posture
D) Presence of abnormal airway sounds - Answers B) Effortless respirations
Which of the following is NOT a sign of increased work of breathing?
A) Supraclavicular retractions
B) Head bobbing in infants
C) Effortless respirations
D) Nasal flaring - Answers C) Effortless respirations
Which assessment finding suggests respiratory distress in an infant?
,A) Absence of retractions
B) Head bobbing
C) Strong cry
D) Effortless breathing - Answers B) Head bobbing
Where can retractions be felt in a child with increased work of breathing?
A) Over the scapula
B) On the side of the neck
C) At the base of the spine
D) In the upper arms - Answers B) On the side of the neck
Scalene muscle
Nasal flaring during inspiration is an indication of:
A) Increased respiratory effort
B) Decreased respiratory effort
C) Normal spontaneous breathing
D) Cardiac arrest - Answers A) Increased respiratory effort
Which of the following is not considered an abnormal airway sound?
A) Stridor
B) Grunting
C) Wheezing
D) Strong cry
E) Snoring
F) Muffled or hoarse speech - Answers D) Strong cry
Which body positions may indicate respiratory distress? (SATA)
A) Sniffing position
B) Tripoding
, C) Preference for seated posture
D) Supine position
E) Side-lying position - Answers A, B, C
What does pallor indicate in a pediatric patient?
A) Normal skin perfusion
B) Vasodilation and increased blood flow
C) Pale skin or mucous membranes due to poor circulation
D) Increased oxygenation - Answers C) Pale skin or mucous membranes due to poor circulation
Mottling of the skin is caused by:
A) Vasoconstriction leading to patchy skin discoloration
B) Increased blood flow to the skin
C) High levels of oxygen saturation
D) A normal variation in skin tone - Answers A) Vasoconstriction leading to patchy skin
discoloration
Cyanosis is best described as:
A) A deep red skin discoloration
B) Bluish or grayish discoloration of the skin and mucous membranes
C) Yellowing of the skin due to liver dysfunction
D) A normal finding in infants - Answers B) Bluish or grayish discoloration of the skin and
mucous membranes
Which of the following findings may indicate poor circulation in a pediatric patient?
A) Flushed, warm skin
B) Sunken eyes
C) Strong peripheral pulses
D) Pink and moist mucous membranes - Answers B) Sunken eyes
What does "A" stand for in the ABCDEFGHI primary assessment?
What are the three components of the Paediatric Assessment Triangle?
A) Appearance, breathing, circulation
B) Heart rate, respiratory rate, oxygen saturation
C) Blood pressure, temperature, skin color
D) Reflexes, muscle strength, pupil reaction - Answers A) Appearance, breathing, circulation
The Pediatric Assessment Triangle is conducted as a(n):
A) Hands-on physical examination
B) Cross-the-room assessment
C) Laboratory test for pediatric patients
D) Detailed neurological evaluation - Answers B) Cross-the-room assessment
Look and listen
What is the primary purpose of the Paediatric Assessment Triangle?
A) To determine if a child needs immediate intervention
B) To establish a definitive diagnosis
C) To measure vital signs accurately
D) To perform a detailed cardiovascular examination - Answers A) To determine if a child needs
immediate intervention
Which of the following is NOT a component of the "general appearance" assessment?
A) Tone
B) Interactiveness
C) Blood pressure
D) Consolability - Answers C) Blood pressure
Match each aspect of general appearance to the correct description.
1. Tone
2. Interactiveness
,3. Consolability
4. Look/gaze
5. Speech/cry
A) Appears alert and engaged with clinician or caregiver, interacts with people and environment,
reaches for toys, objects
B) Makes eye contact with clinician, tracks visually
C) Moves spontaneously, resists examination, sits/stands (age appropriate)
D) Has strong cry, uses age-appropriate speech
E) Stops crying when held and comforted by caregiver, has differential response to caregiver vs
examiner - Answers 1. C
2. A
3. E
4. B
5. D
Which of the following describes normal spontaneous breathing?
A) Increased work of breathing
B) Effortless respirations
C) Tripoding posture
D) Presence of abnormal airway sounds - Answers B) Effortless respirations
Which of the following is NOT a sign of increased work of breathing?
A) Supraclavicular retractions
B) Head bobbing in infants
C) Effortless respirations
D) Nasal flaring - Answers C) Effortless respirations
Which assessment finding suggests respiratory distress in an infant?
,A) Absence of retractions
B) Head bobbing
C) Strong cry
D) Effortless breathing - Answers B) Head bobbing
Where can retractions be felt in a child with increased work of breathing?
A) Over the scapula
B) On the side of the neck
C) At the base of the spine
D) In the upper arms - Answers B) On the side of the neck
Scalene muscle
Nasal flaring during inspiration is an indication of:
A) Increased respiratory effort
B) Decreased respiratory effort
C) Normal spontaneous breathing
D) Cardiac arrest - Answers A) Increased respiratory effort
Which of the following is not considered an abnormal airway sound?
A) Stridor
B) Grunting
C) Wheezing
D) Strong cry
E) Snoring
F) Muffled or hoarse speech - Answers D) Strong cry
Which body positions may indicate respiratory distress? (SATA)
A) Sniffing position
B) Tripoding
, C) Preference for seated posture
D) Supine position
E) Side-lying position - Answers A, B, C
What does pallor indicate in a pediatric patient?
A) Normal skin perfusion
B) Vasodilation and increased blood flow
C) Pale skin or mucous membranes due to poor circulation
D) Increased oxygenation - Answers C) Pale skin or mucous membranes due to poor circulation
Mottling of the skin is caused by:
A) Vasoconstriction leading to patchy skin discoloration
B) Increased blood flow to the skin
C) High levels of oxygen saturation
D) A normal variation in skin tone - Answers A) Vasoconstriction leading to patchy skin
discoloration
Cyanosis is best described as:
A) A deep red skin discoloration
B) Bluish or grayish discoloration of the skin and mucous membranes
C) Yellowing of the skin due to liver dysfunction
D) A normal finding in infants - Answers B) Bluish or grayish discoloration of the skin and
mucous membranes
Which of the following findings may indicate poor circulation in a pediatric patient?
A) Flushed, warm skin
B) Sunken eyes
C) Strong peripheral pulses
D) Pink and moist mucous membranes - Answers B) Sunken eyes
What does "A" stand for in the ABCDEFGHI primary assessment?
