Exam 4 Exam P3 UPDATED ACTUAL Questions and CORRECT
Answers
Question: Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child? Have
the child blow a pinwheel. Have the child hop on one foot. Have the child say 99, 99, 99. Have the child
skip around the room.
Correct Answer: Have the child blow a pinwheel. Explanation: The nurse can assure adequate deep
breaths for assessment of lung sounds by having the child blow a pinwheel. Having the child say 99, 99, 99
assesses the density of the lung tissue not breath sounds. Hopping on one foot and skipping around the room
gives the nurse information regarding the child's sense of balance and motor development.
Question: The nurse is performing an assessment on a child. How should the blood pressure cuff fit on the
child's arm? The cuff should cover 80% of the child's upper arm. The cuff should cover 40% of the child's
upper arm. The cuff should cover 50% of the child's upper arm. The cuff should cover 65% of the child's
upper arm.
Correct Answer: The cuff should cover 80% of the child's upper arm. Explanation: The blood pressure
cuff should cover 80% of the child's upper arm.
Question: The nurse has assessed the head circumference (HC) of an 18-month-old during a regular
checkup. The nurse should compare the percentile of the child's HC to which of the following? The child's
body mass index The child's height and weight percentiles The child's chest circumference percentile The
child's developmental stage
Correct Answer: The child's height and weight percentiles Explanation: HC (OFC) measurement should
fall between the 5th and 95th percentiles and should be comparable to the child's height and weight
percentiles. BMI is not normally applied to young children. HC is not evaluated in light of chest
circumference or psychosocial development.
Question: The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the
following should the nurse suspect? Appendicitis Otitis media Hypospadias Cryptorchidism
Correct Answer: Appendicitis Explanation: Abdominal pain and vomiting are classic clinical
manifestations of appendicitis. Otitis media causes an ear ache but not vomiting. Hypospadias is an
abnormal opening of the urethra on the underside of the penis. Cryptorchidism is a term to describe
undescended testicles. Hypospadias and cryptorchidism do not cause pain and vomiting.
Question: A school nurse plans to test hearing acuity in students who range between kindergarten and sixth
grade. What would be best initial screening method for the students? Denver Developmental Screening Test
audiometry whisper test QUESTT mnemonic
Correct Answer: whisper test Explanation: The whisper test would be the best initial hearing acuity test to
screen school-age children. If hearing deficit is suspected, complete audiometric testing should be
performed. The QUESTT mnemonic is a tool used for assessing pain. The Denver Developmental
Screening Test is a tool used to screen for cognitive, language, social, and gross and fine motor
developmental delays.
Question: How should the nurse document normal range of motion (ROM) in a child? ROM full with
4-5+/5 strength symmetrically ROM full ROM strength symmetrically ROM WNL
Correct Answer: ROM full with 4-5+/5 strength symmetrically Explanation: In children, nurses observe
for ROM and musculoskeletal symmetry and coordination. Normal ROM for them is full with 4-5+/5
,strength symmetrically. ROM full is not acceptable because it is not a complete documentation. A ROM of ,
regardless of whether the strength is symmetrical, is not an expected finding for a child. The initials WNL
mean a range, not a specific finding.
Question: A nurse is inspecting the anus of a 5-year-old. Which of the following findings should be a cause
of concern for the nurse? Anal opening is moist and hairless Perianal skin tags are present A dark ring is
present around the anus The skin is smooth and without lesions
Correct Answer: A dark ring is present around the anus Explanation: A dark ring around the anus may
indicate heavy-metal poisoning. The anal opening should be visible, moist, and hairless. No hemorrhoids or
lesions should be present. Perianal skin should be smooth and free of lesions. A mild diaper rash (red
papules) may be seen in infants. Perianal skin tags may be noted.
Question: The nurse identifies the need to assess a child's motor, language and social development. What
test would be most appropriate? Denver Developmental Screening Apgar Scoring Hirschberg Screening
Blackboard Screening
Correct Answer: Denver Developmental Screening Explanation: The Denver Developmental Screening
Test is used for the developmental evaluation of children aged 1 month to 6 years. It evaluates
personal/social, language, fine and gross motor skills. Blackboard and Hirschberg are vision screening
exams. The Apgar is calculated at 1 and 5 minutes after birth.
Question: Upon inspection of the external eyes of a child, which position should indicate to the nurse that
the eyes are properly located? Epicanthal folds partially cover the inner canthus Outer canthus aligns with
the tip of the pinna Corneal reflex is in the same location in both eyes Eyebrows are symmetrical in shape
over the eyes
Correct Answer: Outer canthus aligns with the tip of the pinna Explanation: Proper location of the eyes is
present when the outer canthus aligns with the tip of the pinna of the ear. Epicanthal folds are excesses of
skin that cover the inner canthus of the eyes. This is a normal finding in Asian individuals. The reflection of
the light on the cornea in the same location indicates parallel alignment. Symmetrical eyebrows are not an
indication of eye location.
Question: The nurse is evaluating the results of a 11-month-old who underwent visual reinforcement
audiometry. When interpreting the results, the nurse recognizes that
Correct Answer: Unilateral hearing loss cannot be ruled out. The test is ear specific in its assessment.
Cortical processing of sound is not assessed. The cooperation of the child affects the obtained information.:
Unilateral hearing loss cannot be ruled out. Explanation: Visual reinforcement audiometry assesses cortical
processing of sound but is not ear-specific. The test only assesses the hearing of the better ear. Therefore, a
unilateral hearing loss cannot be ruled out. Cooperation of the child is not required and does not influence
the test.
Question: A child is repeatedly observed using the hand to push the nose upwards and backwards. What
associated physical sign should the nurse assess for? thin lips a palpable goiter discoloration of the lower
orbitopalpebral grooves Brushfield's spots
Correct Answer: discoloration of the lower orbitopalpebral grooves Explanation: The described behavior
is frequently associated with perennial allergic rhinitis. Edema and discoloration of the lower
orbitopalpebral grooves ("allergic shiners") is also a common characteristic of this disorder. Thin lips are
associated with fetal alcohol syndrome. An enlarged thyroid gland (goiter) is not a characteristic of
perennial allergic rhinitis but rather of hyperthyroidism. Brushfield's spots, abnormal speckling spots on the
iris, suggest Down syndrome.
, Question: The nurse is conducting a vision-screening program for children age 3 to 10 years. The nurse
would expect a child to have vision at what age (in years)? 3 to 4 4 to 5 5 to 6 6 to 7
Correct Answer: 6 to 7 Explanation: Visual acuity of typically is achieved by ages 6 to 7 years.
Question: A nurse has completed an assessment of a school-age child. The nurse has identified several
"soft signs" of potential neurologic impairment. How should the nurse best interpret these findings?
Recognize that the findings are related to developmental tasks, not neurologic pathology. Recognize the
need for an emergency neurological assessment. Recognize that the findings may or may not indicate the
presence of a neurologic problem. Recognize that the findings need to be interpreting in light of the child's
education level.
Correct Answer: Recognize that the findings may or may not indicate the presence of a neurologic
problem. Explanation: Soft signs of neurologic problems are controversial, because these signs do not
always indicate a pathologic process. Referral may be necessary, but not likely on an emergency basis.
These signs are unlikely to be closely related to educational level or developmental tasks.
Question: When interviewing an adolescent, which health issue would be least appropriate to discuss with
the client while a parent is present? Nutrition Immunizations Sexuality Sleep patterns
Correct Answer: Sexuality Explanation: Sensitive issues such as sexuality, drugs, and alcohol use are best
handled without the parents present to preserve privacy, confidentiality, and trust. General health issues,
such as nutrition, sleep patterns, and immunizations, may or may not be discussed with the parent present.
Question: A child 2 years of age or older should consume no more than 2,400 mg/day ofwhat element?
Magnesium Calcium Potassium Sodium
Correct Answer: Sodium Explanation: Children aged 2 years and older should consume daily less than
10% of calories from saturated fat, no more than 30% of calories from total fat, and 2,400 mg or less of
sodium; they also need to meet dietary recommendations for calcium.
Question: The nurse is assessing Tommy, an 18-month-old. The mother expresses concern that Tommy
coos and babbles but does not say distinct words like her other children did at this age. Which conclusion by
the nurse is most appropriate? Tommy is exhibiting expected behavior as development of children varies.
This is not an expected finding and requires further evaluation immediately. The nurse recognizes that the
mother is over-reacting to the child's behavior. This is not an expected finding; a follow up assessment is
needed in 6 months.-
Correct Answer: This is not an expected finding and requires further evaluation immediately. Explanation:
Tommy is not exhibiting expected language/speech development for an 18-month-old and requires further
evaluation immediately. A delay in language/speech development may be related to a hearing loss or a
possible mental health issue.
Question: In the older adult, which changes in the peripheral vascular system can increase blood pressure?
Arterial walls are less elastic and stiffen Arterial walls are more elastic and compliant Venous walls are less
elastic and stiffen Venous return slows and increases afterload on the left ventricle
Correct Answer: Arterial walls are less elastic and stiffen Explanation: Changes in connective and smooth
muscle tissue affect the peripheral vessels and heart. Arterial walls are less elastic and stiffen. Subsequent
decreased compliance affects blood pressure by increasing the afterload on the left ventricle. Systolic blood
pressure increases, the left ventricle wall hypertrophies or thickens, and there is an increased dependence on
atrial contraction. Coronary artery blood flow decreases by about one third.
Answers
Question: Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child? Have
the child blow a pinwheel. Have the child hop on one foot. Have the child say 99, 99, 99. Have the child
skip around the room.
Correct Answer: Have the child blow a pinwheel. Explanation: The nurse can assure adequate deep
breaths for assessment of lung sounds by having the child blow a pinwheel. Having the child say 99, 99, 99
assesses the density of the lung tissue not breath sounds. Hopping on one foot and skipping around the room
gives the nurse information regarding the child's sense of balance and motor development.
Question: The nurse is performing an assessment on a child. How should the blood pressure cuff fit on the
child's arm? The cuff should cover 80% of the child's upper arm. The cuff should cover 40% of the child's
upper arm. The cuff should cover 50% of the child's upper arm. The cuff should cover 65% of the child's
upper arm.
Correct Answer: The cuff should cover 80% of the child's upper arm. Explanation: The blood pressure
cuff should cover 80% of the child's upper arm.
Question: The nurse has assessed the head circumference (HC) of an 18-month-old during a regular
checkup. The nurse should compare the percentile of the child's HC to which of the following? The child's
body mass index The child's height and weight percentiles The child's chest circumference percentile The
child's developmental stage
Correct Answer: The child's height and weight percentiles Explanation: HC (OFC) measurement should
fall between the 5th and 95th percentiles and should be comparable to the child's height and weight
percentiles. BMI is not normally applied to young children. HC is not evaluated in light of chest
circumference or psychosocial development.
Question: The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the
following should the nurse suspect? Appendicitis Otitis media Hypospadias Cryptorchidism
Correct Answer: Appendicitis Explanation: Abdominal pain and vomiting are classic clinical
manifestations of appendicitis. Otitis media causes an ear ache but not vomiting. Hypospadias is an
abnormal opening of the urethra on the underside of the penis. Cryptorchidism is a term to describe
undescended testicles. Hypospadias and cryptorchidism do not cause pain and vomiting.
Question: A school nurse plans to test hearing acuity in students who range between kindergarten and sixth
grade. What would be best initial screening method for the students? Denver Developmental Screening Test
audiometry whisper test QUESTT mnemonic
Correct Answer: whisper test Explanation: The whisper test would be the best initial hearing acuity test to
screen school-age children. If hearing deficit is suspected, complete audiometric testing should be
performed. The QUESTT mnemonic is a tool used for assessing pain. The Denver Developmental
Screening Test is a tool used to screen for cognitive, language, social, and gross and fine motor
developmental delays.
Question: How should the nurse document normal range of motion (ROM) in a child? ROM full with
4-5+/5 strength symmetrically ROM full ROM strength symmetrically ROM WNL
Correct Answer: ROM full with 4-5+/5 strength symmetrically Explanation: In children, nurses observe
for ROM and musculoskeletal symmetry and coordination. Normal ROM for them is full with 4-5+/5
,strength symmetrically. ROM full is not acceptable because it is not a complete documentation. A ROM of ,
regardless of whether the strength is symmetrical, is not an expected finding for a child. The initials WNL
mean a range, not a specific finding.
Question: A nurse is inspecting the anus of a 5-year-old. Which of the following findings should be a cause
of concern for the nurse? Anal opening is moist and hairless Perianal skin tags are present A dark ring is
present around the anus The skin is smooth and without lesions
Correct Answer: A dark ring is present around the anus Explanation: A dark ring around the anus may
indicate heavy-metal poisoning. The anal opening should be visible, moist, and hairless. No hemorrhoids or
lesions should be present. Perianal skin should be smooth and free of lesions. A mild diaper rash (red
papules) may be seen in infants. Perianal skin tags may be noted.
Question: The nurse identifies the need to assess a child's motor, language and social development. What
test would be most appropriate? Denver Developmental Screening Apgar Scoring Hirschberg Screening
Blackboard Screening
Correct Answer: Denver Developmental Screening Explanation: The Denver Developmental Screening
Test is used for the developmental evaluation of children aged 1 month to 6 years. It evaluates
personal/social, language, fine and gross motor skills. Blackboard and Hirschberg are vision screening
exams. The Apgar is calculated at 1 and 5 minutes after birth.
Question: Upon inspection of the external eyes of a child, which position should indicate to the nurse that
the eyes are properly located? Epicanthal folds partially cover the inner canthus Outer canthus aligns with
the tip of the pinna Corneal reflex is in the same location in both eyes Eyebrows are symmetrical in shape
over the eyes
Correct Answer: Outer canthus aligns with the tip of the pinna Explanation: Proper location of the eyes is
present when the outer canthus aligns with the tip of the pinna of the ear. Epicanthal folds are excesses of
skin that cover the inner canthus of the eyes. This is a normal finding in Asian individuals. The reflection of
the light on the cornea in the same location indicates parallel alignment. Symmetrical eyebrows are not an
indication of eye location.
Question: The nurse is evaluating the results of a 11-month-old who underwent visual reinforcement
audiometry. When interpreting the results, the nurse recognizes that
Correct Answer: Unilateral hearing loss cannot be ruled out. The test is ear specific in its assessment.
Cortical processing of sound is not assessed. The cooperation of the child affects the obtained information.:
Unilateral hearing loss cannot be ruled out. Explanation: Visual reinforcement audiometry assesses cortical
processing of sound but is not ear-specific. The test only assesses the hearing of the better ear. Therefore, a
unilateral hearing loss cannot be ruled out. Cooperation of the child is not required and does not influence
the test.
Question: A child is repeatedly observed using the hand to push the nose upwards and backwards. What
associated physical sign should the nurse assess for? thin lips a palpable goiter discoloration of the lower
orbitopalpebral grooves Brushfield's spots
Correct Answer: discoloration of the lower orbitopalpebral grooves Explanation: The described behavior
is frequently associated with perennial allergic rhinitis. Edema and discoloration of the lower
orbitopalpebral grooves ("allergic shiners") is also a common characteristic of this disorder. Thin lips are
associated with fetal alcohol syndrome. An enlarged thyroid gland (goiter) is not a characteristic of
perennial allergic rhinitis but rather of hyperthyroidism. Brushfield's spots, abnormal speckling spots on the
iris, suggest Down syndrome.
, Question: The nurse is conducting a vision-screening program for children age 3 to 10 years. The nurse
would expect a child to have vision at what age (in years)? 3 to 4 4 to 5 5 to 6 6 to 7
Correct Answer: 6 to 7 Explanation: Visual acuity of typically is achieved by ages 6 to 7 years.
Question: A nurse has completed an assessment of a school-age child. The nurse has identified several
"soft signs" of potential neurologic impairment. How should the nurse best interpret these findings?
Recognize that the findings are related to developmental tasks, not neurologic pathology. Recognize the
need for an emergency neurological assessment. Recognize that the findings may or may not indicate the
presence of a neurologic problem. Recognize that the findings need to be interpreting in light of the child's
education level.
Correct Answer: Recognize that the findings may or may not indicate the presence of a neurologic
problem. Explanation: Soft signs of neurologic problems are controversial, because these signs do not
always indicate a pathologic process. Referral may be necessary, but not likely on an emergency basis.
These signs are unlikely to be closely related to educational level or developmental tasks.
Question: When interviewing an adolescent, which health issue would be least appropriate to discuss with
the client while a parent is present? Nutrition Immunizations Sexuality Sleep patterns
Correct Answer: Sexuality Explanation: Sensitive issues such as sexuality, drugs, and alcohol use are best
handled without the parents present to preserve privacy, confidentiality, and trust. General health issues,
such as nutrition, sleep patterns, and immunizations, may or may not be discussed with the parent present.
Question: A child 2 years of age or older should consume no more than 2,400 mg/day ofwhat element?
Magnesium Calcium Potassium Sodium
Correct Answer: Sodium Explanation: Children aged 2 years and older should consume daily less than
10% of calories from saturated fat, no more than 30% of calories from total fat, and 2,400 mg or less of
sodium; they also need to meet dietary recommendations for calcium.
Question: The nurse is assessing Tommy, an 18-month-old. The mother expresses concern that Tommy
coos and babbles but does not say distinct words like her other children did at this age. Which conclusion by
the nurse is most appropriate? Tommy is exhibiting expected behavior as development of children varies.
This is not an expected finding and requires further evaluation immediately. The nurse recognizes that the
mother is over-reacting to the child's behavior. This is not an expected finding; a follow up assessment is
needed in 6 months.-
Correct Answer: This is not an expected finding and requires further evaluation immediately. Explanation:
Tommy is not exhibiting expected language/speech development for an 18-month-old and requires further
evaluation immediately. A delay in language/speech development may be related to a hearing loss or a
possible mental health issue.
Question: In the older adult, which changes in the peripheral vascular system can increase blood pressure?
Arterial walls are less elastic and stiffen Arterial walls are more elastic and compliant Venous walls are less
elastic and stiffen Venous return slows and increases afterload on the left ventricle
Correct Answer: Arterial walls are less elastic and stiffen Explanation: Changes in connective and smooth
muscle tissue affect the peripheral vessels and heart. Arterial walls are less elastic and stiffen. Subsequent
decreased compliance affects blood pressure by increasing the afterload on the left ventricle. Systolic blood
pressure increases, the left ventricle wall hypertrophies or thickens, and there is an increased dependence on
atrial contraction. Coronary artery blood flow decreases by about one third.
