HEENT Test Questions &
Answers
The nurse palpates the lymph nodes of a child. The lymph nodes are palpable, 0.5 cm, and firm.
How should the nurse interpret this finding? - ANSWERSThese assessment findings are
considered normal for the pediatric patient.Children often have small, palpable, firm lymph
nodes. This is considered a normal assessment finding.
The pediatric nurse assesses a newborn and notes strabismus. What should be the nurse's initial
response? - ANSWERSContinue to monitor the newborn for vision problems.
Strabismus is a normal finding in a newborn but should be transient. The nurse should continue
to assess for any other vision problems or consistent strabismus.
The nurse is concerned that the infant may have microcephaly. What should be the nurse's
initial action? - ANSWERSMeasure the newborn's head circumference.Measuring head
circumference will give an indication if the child has microcephaly. This measurement needs to
be done at every visit for the first two years of life
A 5-year-old child is nervous about having his mouth inspected. What is the best action for the
nurse to take before beginning the assessment? - ANSWERSDemonstrate the assessment on the
parent of the child so the child can see that it does not cause pain.
A 5-year-old will likely feel less anxious after seeing what the exam entails and how it is going to
be performed on a trusted caregiver such as a parent.
The nurse is preparing a 4-year-old for an internal ear exam. How should the nurse position the
child? - ANSWERSThe head of the child should be slightly tilted and the pinna pulled up and
back.
The pinna should be pulled up and back for children older than 3.
, The nurse is preparing for vision screening on an 8-year-old. What assessment tools should the
nurse use?Select all that apply. - ANSWERSAn eye cover
An eye cover is used for several vision tests including the Snellen chart.
A Snellen chart
A Snellen chart is appropriate for testing the visual acuity of an 8-year-old.
An Ishihara chart
The nurse should be prepared to perform this screening of color vision because it should be
performed at least once between the ages of 4 and 8.
A nondistracting environmentAny screenings should be performed in a nondistracting
environment to help increase accuracy and efficiency of the examination.
The parents of a 5-year-old child bring her into the health care provider's office because of
concerns about her performance in kindergarten. The parents say she is bright but seems to be
having trouble paying attention and following the activities done at the front of the class. What
additional information would the nurse want to gather? - ANSWERSA history of the child
squinting or head tilting to facilitate seeing far away
Head tilting and squinting, along with difficulty seeing the front of a classroom, decreased
attention span, and poor school performance can indicate myopia.
Which scenario illustrates an effective way to test hearing ACUITY in an INFANT? - ANSWERSThe
nurse has the parent stand behind the baby and talk to see if the infant responds to the
voice.An infant should respond to the voice of a parent by trying to locate the parent.
The nurse is assessing the newborn's head and suspects increased intracranial pressure. What
assessment information did the nurse use to reach this conclusion?Select all that apply. -
ANSWERSBulging fontanels at rest
Bulging fontanels at rest are an abnormal finding that indicates increased intracranial pressure.
Answers
The nurse palpates the lymph nodes of a child. The lymph nodes are palpable, 0.5 cm, and firm.
How should the nurse interpret this finding? - ANSWERSThese assessment findings are
considered normal for the pediatric patient.Children often have small, palpable, firm lymph
nodes. This is considered a normal assessment finding.
The pediatric nurse assesses a newborn and notes strabismus. What should be the nurse's initial
response? - ANSWERSContinue to monitor the newborn for vision problems.
Strabismus is a normal finding in a newborn but should be transient. The nurse should continue
to assess for any other vision problems or consistent strabismus.
The nurse is concerned that the infant may have microcephaly. What should be the nurse's
initial action? - ANSWERSMeasure the newborn's head circumference.Measuring head
circumference will give an indication if the child has microcephaly. This measurement needs to
be done at every visit for the first two years of life
A 5-year-old child is nervous about having his mouth inspected. What is the best action for the
nurse to take before beginning the assessment? - ANSWERSDemonstrate the assessment on the
parent of the child so the child can see that it does not cause pain.
A 5-year-old will likely feel less anxious after seeing what the exam entails and how it is going to
be performed on a trusted caregiver such as a parent.
The nurse is preparing a 4-year-old for an internal ear exam. How should the nurse position the
child? - ANSWERSThe head of the child should be slightly tilted and the pinna pulled up and
back.
The pinna should be pulled up and back for children older than 3.
, The nurse is preparing for vision screening on an 8-year-old. What assessment tools should the
nurse use?Select all that apply. - ANSWERSAn eye cover
An eye cover is used for several vision tests including the Snellen chart.
A Snellen chart
A Snellen chart is appropriate for testing the visual acuity of an 8-year-old.
An Ishihara chart
The nurse should be prepared to perform this screening of color vision because it should be
performed at least once between the ages of 4 and 8.
A nondistracting environmentAny screenings should be performed in a nondistracting
environment to help increase accuracy and efficiency of the examination.
The parents of a 5-year-old child bring her into the health care provider's office because of
concerns about her performance in kindergarten. The parents say she is bright but seems to be
having trouble paying attention and following the activities done at the front of the class. What
additional information would the nurse want to gather? - ANSWERSA history of the child
squinting or head tilting to facilitate seeing far away
Head tilting and squinting, along with difficulty seeing the front of a classroom, decreased
attention span, and poor school performance can indicate myopia.
Which scenario illustrates an effective way to test hearing ACUITY in an INFANT? - ANSWERSThe
nurse has the parent stand behind the baby and talk to see if the infant responds to the
voice.An infant should respond to the voice of a parent by trying to locate the parent.
The nurse is assessing the newborn's head and suspects increased intracranial pressure. What
assessment information did the nurse use to reach this conclusion?Select all that apply. -
ANSWERSBulging fontanels at rest
Bulging fontanels at rest are an abnormal finding that indicates increased intracranial pressure.
