Child & Family Nursing Exam 1
Questions With Correct Marking
Scheme
An 8-year-old girl asks the nurse how the blood pressure equipment works. The
most appropriate nursing action is to
a. ask her why she wants to know.
b. determine why she is so anxious.
c. explain in simple terms how it works.
d. tell her she will see how it works as it is used.
ANS: C
School-age children require explanations and reasons for everything. They are
interested in the functional aspect of all procedures, objects, and activities. It is
appropriate for the nurse to explain how equipment works and what will happen to the
child. ―Why‖ questions are not therapeutic, plus this question makes it sound like the
nurse thinks the child does not need this information. The child is not exhibiting anxiety,
just requesting clarification of what will be
occurring. The nurse must explain how the blood pressure cuff works so that the child
can then observe during the procedure.
Which action is appropriate when the nurse is assessing breath sounds of an 18-
month-old
crying child?
a. Ask the parent to quiet the child so the nurse can listen.
b. Auscultate breath sounds and chart that the child was crying.
c. Let the child play with the stethoscope for distraction.
d. Document that data are not available because of crying.
ANS: C
Distracting the child with an interesting activity can assist the child to calm down so an
accurate assessment can be made. Asking a parent to quiet the child may or may not
work.
Auscultating while the child is crying typically results in suboptimal data. The
assessment
needs to be completed so documenting that data are not available is not appropriate.
A nurse is reviewing pediatric physical assessment techniques. Which statement
about
performing a pediatric physical assessment is correct?
a. Physical examinations proceed systematically from head to toe unless
developmental considerations dictate otherwise.
b. The physical examination should be done with parents in the examining room
for
,children of any age.
c. Measurement of head circumference is done until the child is 5 years old.
d. The physical examination is done only when the child is cooperative.
ANS: A
Physical assessment usually proceeds from head to toe; however, developmental
considerations with infants and toddlers dictate that the least threatening assessments
be done
first to obtain accurate data. Having parents in the examining room with adolescents is
not
appropriate. Head circumference is routinely measured until 36 months of age. Children
will
not always be cooperative during the physical examination. The examiner will need to
incorporate communication and play techniques to facilitate cooperation.
The nurse is assessing a 4-year-old child's visual acuity. The results indicate a
visual acuity of
20/40 in both eyes. The child's father asks the nurse about his son's results.
Which response,
if made by the nurse, is correct?
a. ―Your child will need a referral to the ophthalmologist before he can attend
preschool next week.‖
b. ―Your child's visual acuity is normal for his age.‖
c. ―The results of this test indicate your child may be color blind.‖
d. ―Your child did not pass; he will need to see an eye doctor.‖
ANS: B
Normal visual acuity for a 4-year-old is 20/40 to 20/50. This finding is normal. No other
action is needed.
Which assessment finding is considered a neurologic soft sign in a 7-year-old
child?
a. Plantar reflex
b. Poor muscle coordination
c. Stereognostic function
d. Graphesthesia
ANS: B
Poor muscle coordination is a neurologic soft sign. The plantar reflex is a normal
response.
Stereognostic function refers to the ability to identify familiar objects placed in each
hand.
Graphesthesia is the ability to identify letters or numbers traced on the palm or back of
the
hand with a blunt point.
When palpating the child's cervical lymph nodes, the nurse notes that they are
tender,
enlarged, and warm. What is the best explanation for this?
a. Some form of cancer
b. Local scalp infection common in children
,c. Infection or inflammation distal to the site
d. Infection or inflammation close to the site
ANS: D
Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may
indicate
infection or inflammation close to their location. They are not indicative of cancer or
scalp
infection.
What heart sound is produced by vibrations within the heart chambers or in the
major arteries
from the back-and-forth flow of blood?
a. S1, S2
b. Snaps and clicks
c. Murmur
d. Physiologic splitting
ANS: C
Murmurs are the sounds that are produced in the heart chambers or major arteries from
the
turbulence of blood flow. Murmurs create a blowing and swooshing sound. S1 and S2
are the
normal heart sounds. Snaps and clicks are short, high-pitched sounds heard with valve
disorders and do not vary with respirations. The physiologic splitting of S2, an audible
pause
between the closing of the aortic and pulmonic valves, frequently heard in children of all
ages,
is considered normal.
The nurse has a 2-year-old boy sit in a ―tailor‖ position during palpation for the
testes. What is
the rationale for this position?
a. It prevents cremasteric reflex.
b. Undescended testes can be palpated.
c. This tests the child for an inguinal hernia.
d. The child does not yet have a need for privacy.
ANS: A
The tailor position stretches the muscle responsible for the cremasteric reflex. This
prevents
its contraction, which pulls the testes into the pelvic cavity.
During examination of a toddler's extremities, the nurse notes that the child is
bowlegged.
The nurse should recognize that this finding is
a. abnormal, requiring further investigation.
b. abnormal unless it occurs in conjunction with knock-knee.
c. normal if the condition is unilateral or asymmetric.
d. normal, because the lower back and leg muscles are not yet well developed.
ANS: D
Genu varum (bowlegged) is common in toddlers when they begin to walk. It usually
, persists
until all of their lower back and leg muscles are well developed, usually by age 3.
Kimberly is having a checkup before starting kindergarten. The nurse asks her to
do the
―finger-to-nose‖ test. The nurse is testing for
a. deep tendon reflexes.
b. cerebellar function.
c. sensory discrimination.
d. ability to follow directions.
ANS: B
The finger-to-nose-test is an indication of cerebellar function. This test checks balance
and
coordination. It does not assess DTRs, sensory discrimination, or the ability to follow
directions.
Which statements about performing a pediatric physical assessment are correct
for a
school-age child? (Select all that apply.)
a. Physical examinations proceed systematically from head to toe.
b. The physical examination should be done with parents in the waiting room.
c. Measurement of head circumference is obtained.
d. The physical examination is done only when the child is cooperative.
e. Remove clothing and have the child put on an examination gown.
ANS: A, D, E
Physical assessment usually proceeds from head to toe; however, if developmental
delays
exist, considerations dictate that the least threatening assessments be done first to
obtain
accurate data. School-age children are at a developmental stage when they should be
cooperative for the physical examination. Children of this age are usually modest, and
an
examination gown should be provided. Having parents in the examining room with
adolescents is not appropriate, but it is appropriate for children of other age-groups.
Parents
usually are not kept in the waiting room. Measurement of head circumference is
obtained on
children 36 months of age or less.
What should the nurse recognize as a possible indicator of child abuse in a 4-
year-old child
being treated for ear pain at the emergency department on a cold winter day?
(Select all that
apply.)
a. The child extends his arms to be hugged by the nurse.
b. The child is wearing clean, baggy shorts, sandals, and an oversized T-shirt.
c. The child answers all questions in complete sentences and smiles afterward.
d. The child has dirty, broken teeth.
e. The child states ―I'm so fat‖ when the nurse tells his mother he weighs 25 lb.
Questions With Correct Marking
Scheme
An 8-year-old girl asks the nurse how the blood pressure equipment works. The
most appropriate nursing action is to
a. ask her why she wants to know.
b. determine why she is so anxious.
c. explain in simple terms how it works.
d. tell her she will see how it works as it is used.
ANS: C
School-age children require explanations and reasons for everything. They are
interested in the functional aspect of all procedures, objects, and activities. It is
appropriate for the nurse to explain how equipment works and what will happen to the
child. ―Why‖ questions are not therapeutic, plus this question makes it sound like the
nurse thinks the child does not need this information. The child is not exhibiting anxiety,
just requesting clarification of what will be
occurring. The nurse must explain how the blood pressure cuff works so that the child
can then observe during the procedure.
Which action is appropriate when the nurse is assessing breath sounds of an 18-
month-old
crying child?
a. Ask the parent to quiet the child so the nurse can listen.
b. Auscultate breath sounds and chart that the child was crying.
c. Let the child play with the stethoscope for distraction.
d. Document that data are not available because of crying.
ANS: C
Distracting the child with an interesting activity can assist the child to calm down so an
accurate assessment can be made. Asking a parent to quiet the child may or may not
work.
Auscultating while the child is crying typically results in suboptimal data. The
assessment
needs to be completed so documenting that data are not available is not appropriate.
A nurse is reviewing pediatric physical assessment techniques. Which statement
about
performing a pediatric physical assessment is correct?
a. Physical examinations proceed systematically from head to toe unless
developmental considerations dictate otherwise.
b. The physical examination should be done with parents in the examining room
for
,children of any age.
c. Measurement of head circumference is done until the child is 5 years old.
d. The physical examination is done only when the child is cooperative.
ANS: A
Physical assessment usually proceeds from head to toe; however, developmental
considerations with infants and toddlers dictate that the least threatening assessments
be done
first to obtain accurate data. Having parents in the examining room with adolescents is
not
appropriate. Head circumference is routinely measured until 36 months of age. Children
will
not always be cooperative during the physical examination. The examiner will need to
incorporate communication and play techniques to facilitate cooperation.
The nurse is assessing a 4-year-old child's visual acuity. The results indicate a
visual acuity of
20/40 in both eyes. The child's father asks the nurse about his son's results.
Which response,
if made by the nurse, is correct?
a. ―Your child will need a referral to the ophthalmologist before he can attend
preschool next week.‖
b. ―Your child's visual acuity is normal for his age.‖
c. ―The results of this test indicate your child may be color blind.‖
d. ―Your child did not pass; he will need to see an eye doctor.‖
ANS: B
Normal visual acuity for a 4-year-old is 20/40 to 20/50. This finding is normal. No other
action is needed.
Which assessment finding is considered a neurologic soft sign in a 7-year-old
child?
a. Plantar reflex
b. Poor muscle coordination
c. Stereognostic function
d. Graphesthesia
ANS: B
Poor muscle coordination is a neurologic soft sign. The plantar reflex is a normal
response.
Stereognostic function refers to the ability to identify familiar objects placed in each
hand.
Graphesthesia is the ability to identify letters or numbers traced on the palm or back of
the
hand with a blunt point.
When palpating the child's cervical lymph nodes, the nurse notes that they are
tender,
enlarged, and warm. What is the best explanation for this?
a. Some form of cancer
b. Local scalp infection common in children
,c. Infection or inflammation distal to the site
d. Infection or inflammation close to the site
ANS: D
Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may
indicate
infection or inflammation close to their location. They are not indicative of cancer or
scalp
infection.
What heart sound is produced by vibrations within the heart chambers or in the
major arteries
from the back-and-forth flow of blood?
a. S1, S2
b. Snaps and clicks
c. Murmur
d. Physiologic splitting
ANS: C
Murmurs are the sounds that are produced in the heart chambers or major arteries from
the
turbulence of blood flow. Murmurs create a blowing and swooshing sound. S1 and S2
are the
normal heart sounds. Snaps and clicks are short, high-pitched sounds heard with valve
disorders and do not vary with respirations. The physiologic splitting of S2, an audible
pause
between the closing of the aortic and pulmonic valves, frequently heard in children of all
ages,
is considered normal.
The nurse has a 2-year-old boy sit in a ―tailor‖ position during palpation for the
testes. What is
the rationale for this position?
a. It prevents cremasteric reflex.
b. Undescended testes can be palpated.
c. This tests the child for an inguinal hernia.
d. The child does not yet have a need for privacy.
ANS: A
The tailor position stretches the muscle responsible for the cremasteric reflex. This
prevents
its contraction, which pulls the testes into the pelvic cavity.
During examination of a toddler's extremities, the nurse notes that the child is
bowlegged.
The nurse should recognize that this finding is
a. abnormal, requiring further investigation.
b. abnormal unless it occurs in conjunction with knock-knee.
c. normal if the condition is unilateral or asymmetric.
d. normal, because the lower back and leg muscles are not yet well developed.
ANS: D
Genu varum (bowlegged) is common in toddlers when they begin to walk. It usually
, persists
until all of their lower back and leg muscles are well developed, usually by age 3.
Kimberly is having a checkup before starting kindergarten. The nurse asks her to
do the
―finger-to-nose‖ test. The nurse is testing for
a. deep tendon reflexes.
b. cerebellar function.
c. sensory discrimination.
d. ability to follow directions.
ANS: B
The finger-to-nose-test is an indication of cerebellar function. This test checks balance
and
coordination. It does not assess DTRs, sensory discrimination, or the ability to follow
directions.
Which statements about performing a pediatric physical assessment are correct
for a
school-age child? (Select all that apply.)
a. Physical examinations proceed systematically from head to toe.
b. The physical examination should be done with parents in the waiting room.
c. Measurement of head circumference is obtained.
d. The physical examination is done only when the child is cooperative.
e. Remove clothing and have the child put on an examination gown.
ANS: A, D, E
Physical assessment usually proceeds from head to toe; however, if developmental
delays
exist, considerations dictate that the least threatening assessments be done first to
obtain
accurate data. School-age children are at a developmental stage when they should be
cooperative for the physical examination. Children of this age are usually modest, and
an
examination gown should be provided. Having parents in the examining room with
adolescents is not appropriate, but it is appropriate for children of other age-groups.
Parents
usually are not kept in the waiting room. Measurement of head circumference is
obtained on
children 36 months of age or less.
What should the nurse recognize as a possible indicator of child abuse in a 4-
year-old child
being treated for ear pain at the emergency department on a cold winter day?
(Select all that
apply.)
a. The child extends his arms to be hugged by the nurse.
b. The child is wearing clean, baggy shorts, sandals, and an oversized T-shirt.
c. The child answers all questions in complete sentences and smiles afterward.
d. The child has dirty, broken teeth.
e. The child states ―I'm so fat‖ when the nurse tells his mother he weighs 25 lb.
