NURS 226 exam 1 Questions and Correct
Answers
Which assessment is a priority when preparing to conduct a problem-oriented assessment
on a child presenting with stridor?
A) Pulse rate
B) Anxiety level
C) Blood pressure
D) Respiratory effort
D) Respiratory effort
When screening children for scoliosis, which instruction would the nurse give about how to
stand to ensure accurate assessment of the spine?
A) Knees slightly bent and arms at the sides
B) Feet together and arms raised over the head
C) Feet a shoulder width apart and arms crossed over the chest
D) Feet a shoulder width apart and arms hanging loosely at the sides
D) Feet a shoulder width apart and arms hanging loosely at the sides
Which purpose is accomplished by placing a male child in the tailor position to facilitate
assessment of the testes?
A) To prevent the cremasteric reflex from occurring
,B) To lessen pain response while palpating the testes
C) To enhance visual inspection of the testicular area
D) To decrease the child's anxiety during the examination
A) To prevent the cremasteric reflex from occurring
While obtaining the respiratory rate of a newborn in breaths per minute (bpm), which
finding would cause concern?
A) 20 bpm
B) 35 bpm
C) 42 bpm
D) 50 bpm
A) 20 bpm
Which part of the physical examination would be done last when a 5-month-old infant is
lying on the mother's lap?
A) Inspection of the skin and nails
B) Auscultation of heart and lungs
C) Elicitation of the palmar reflex and plantar grasp reflex
D) Speculum examination of the tympanic membranes
D) Speculum examination of the tympanic membranes
Which measurement is used to calculate an infant's body mass index (BMI)?
SELECT ALL THAT APPLY
,A) Height
B) Weight
C) Head circumference
D) Midarm circumference
E) Triceps skinfold thickness
A) Height
B) Weight
Which response would the nurse provide if a mother of a newborn male wonders why her
son's breasts are like female breasts?
A) "Enlarged breast tissue in male infants often indicates a mixed-sex genetic issue."
B) "I have no idea what is wrong with your baby. I will notify the primary healthcare
provider right away."
C) "Enlargement of the breasts can occur with boy or girls in response to circulating
hormones."
D) "Let me examine your baby. Female organs can be swollen at birth and mistaken for
male parts."
C) "Enlargement of the breasts can occur with boy or girls in response to circulating hormones."
Which strategy would the nurse implement to help gain an infant's cooperation during a
physical examination?
, A) Explain each step of the assessment to the infant before performing it
B) Leave the infant on the parent's lap and use distraction when necessary
C) Perform ear, oral, and other uncomfortable procedures at the beginning
D) Perform the assessment in an area in which parents are out of the infant's sight
B) Leave the infant on the parent's lap and use distraction when necessary
After hearing the presence of hyperresonance upon auscultation of an infant's lung fields,
which action does the nurse take regarding this finding?
A) Notify the healthcare provider
B) Request the PRN aerosol treatment
C) Place the infant in a humidified oxygen tent
D) Document the findings in the infant's database
D) Document the findings in the infant's database
Which action does the nurse take next if a 4-year-old child's blood pressure is 78/42
mm/Hg?
A) Call the Rapid Response Team
B) Use a smaller cuff and reevaluate the blood pressure
C) Place the child in Trendelenburg position and reevaluate
D) Notify the healthcare provider (HCP) and request admission for the child
B) Use a smaller cuff and reevaluate the blood pressure
Answers
Which assessment is a priority when preparing to conduct a problem-oriented assessment
on a child presenting with stridor?
A) Pulse rate
B) Anxiety level
C) Blood pressure
D) Respiratory effort
D) Respiratory effort
When screening children for scoliosis, which instruction would the nurse give about how to
stand to ensure accurate assessment of the spine?
A) Knees slightly bent and arms at the sides
B) Feet together and arms raised over the head
C) Feet a shoulder width apart and arms crossed over the chest
D) Feet a shoulder width apart and arms hanging loosely at the sides
D) Feet a shoulder width apart and arms hanging loosely at the sides
Which purpose is accomplished by placing a male child in the tailor position to facilitate
assessment of the testes?
A) To prevent the cremasteric reflex from occurring
,B) To lessen pain response while palpating the testes
C) To enhance visual inspection of the testicular area
D) To decrease the child's anxiety during the examination
A) To prevent the cremasteric reflex from occurring
While obtaining the respiratory rate of a newborn in breaths per minute (bpm), which
finding would cause concern?
A) 20 bpm
B) 35 bpm
C) 42 bpm
D) 50 bpm
A) 20 bpm
Which part of the physical examination would be done last when a 5-month-old infant is
lying on the mother's lap?
A) Inspection of the skin and nails
B) Auscultation of heart and lungs
C) Elicitation of the palmar reflex and plantar grasp reflex
D) Speculum examination of the tympanic membranes
D) Speculum examination of the tympanic membranes
Which measurement is used to calculate an infant's body mass index (BMI)?
SELECT ALL THAT APPLY
,A) Height
B) Weight
C) Head circumference
D) Midarm circumference
E) Triceps skinfold thickness
A) Height
B) Weight
Which response would the nurse provide if a mother of a newborn male wonders why her
son's breasts are like female breasts?
A) "Enlarged breast tissue in male infants often indicates a mixed-sex genetic issue."
B) "I have no idea what is wrong with your baby. I will notify the primary healthcare
provider right away."
C) "Enlargement of the breasts can occur with boy or girls in response to circulating
hormones."
D) "Let me examine your baby. Female organs can be swollen at birth and mistaken for
male parts."
C) "Enlargement of the breasts can occur with boy or girls in response to circulating hormones."
Which strategy would the nurse implement to help gain an infant's cooperation during a
physical examination?
, A) Explain each step of the assessment to the infant before performing it
B) Leave the infant on the parent's lap and use distraction when necessary
C) Perform ear, oral, and other uncomfortable procedures at the beginning
D) Perform the assessment in an area in which parents are out of the infant's sight
B) Leave the infant on the parent's lap and use distraction when necessary
After hearing the presence of hyperresonance upon auscultation of an infant's lung fields,
which action does the nurse take regarding this finding?
A) Notify the healthcare provider
B) Request the PRN aerosol treatment
C) Place the infant in a humidified oxygen tent
D) Document the findings in the infant's database
D) Document the findings in the infant's database
Which action does the nurse take next if a 4-year-old child's blood pressure is 78/42
mm/Hg?
A) Call the Rapid Response Team
B) Use a smaller cuff and reevaluate the blood pressure
C) Place the child in Trendelenburg position and reevaluate
D) Notify the healthcare provider (HCP) and request admission for the child
B) Use a smaller cuff and reevaluate the blood pressure
