NURS226 Exam 1 – Nursing Leadership & Management Practice Questions and
Study Guide
An infant is brought in for a well-child exam and is asleep. What assessment should the nurse
perform first?
a) inspection
b) palpation
c) percussion
d) auscultation - correct answer ✔✔d) auscultation
Rationale: This is the best time to listen and hear the sounds clearly and this should be done
first.
a and b would require moving the infant and could lead to waking them up and making them
irritable.
You are assessing a 6-month-old infant who smiles, coos, and has strong head lag. What
assessment should the nurse make about this infant's development?
a) These findings are normal for the age.
b) The infant could have cognitive impairment.
c) A developmental/neurologic follow-up evaluation is needed.
d) The parent needs to work with the infant to stop the head lag. - correct answer ✔✔c) A
developmental/neurologic follow-up evaluation is needed.
Rationale: Head lag should be gone by 4 months of age. With persistent head lag this requires
follow-up with a specialist.
When measuring a child's length at or under 24 months, what is the most accurate
measurement?
a) Having the child stand up against the tape measure.
b) Measuring the crown-heel length in prone.
,c) Measuring the crown-heel length in supine.
d) Estimate the length. - correct answer ✔✔c) Measuring the crown-heel length in supine.
How is cranial nerve V (trigeminal nerve) assessed? Select all that apply.
a) ask the child to frown, smile, or make a face
b) stick their tongue out
c) chewing or sucking
d) touching a piece of cotton to the side of the face
e) have the child say "ah" and watch for the uvula and soft palate to rise - correct answer ✔✔c)
chewing or sucking
d) touching a piece of cotton to the side of the face
Rationale: a) Cranial nerve VII (facial nerve)
b) XII (Hypoglossal)
e) IX (glossopharyngeal) AND X (vagus)
You are assessing a preschoolers chest and breathing. What is a normal finding?
a) Respiratory movements are primarily thoracic.
b) Anteroposterior diameter is equal to the transverse diameter.
c) Retractions on inspiration.
d) Movement of the chest wall is symmetrical bilaterally and coordinated with breathing. -
correct answer ✔✔d) Movement of the chest wall is symmetrical bilaterally and coordinated
with breathing.
Rationale: c) rapid respirations, retractions, nasal flaring, and head bobbing may indicate
respiratory difficulty, by preschool years the child's breathing is more coordinated
You are working in the ED when a child is brought in for a cervical neck injury that occurred an
hour prior. Their level of consciousness has been variable since. What is the most essential
assessment to complete?
,a) Perform a fundoscopic examination to identify papilledema.
b) Check pupil reactivity.
c) Perform a doll's head maneuver.
d) Obtain an oculovestibular response. - correct answer ✔✔b) Check pupil reactivity.
Rationale: PERRLA should be performed.
a) papilledema does not present itself until 24-48 hours of unconsciousness and requires
specialty training. c) should not be done a a cervical injury. d) painful, and should not be done
on someone with altering levels of consciousness.
You are preparing to assess an infants lungs sounds but the mother is holding her on her
stomach and she is sleeping. What techniques could be used to get an accurate assessment?
Select all that apply.
a) Gently turn her on her back at the beginning of the assessment.
b) Warm the stethoscope head before placing it on the infant's shirt.
c) Assess the lungs from the apex to the base bilaterally.
d) Identify hyperresonance as normal r/t thin chest walls.
e) Place the infant flat while auscultating the lungs.
f) Auscultate the lung sounds through her back. - correct answer ✔✔c) Assess the lungs from
the apex to the base bilaterally.
d) Identify hyperresonance as normal r/t thin chest walls.
f) Auscultate the lung sounds through her back.
Rationale:
a) Don't want to upset her. b) Should place the head of the stethoscope directly on the skin. e)
elevation of the head while auscultating the lungs allows for a more accurate assessment.
While performing an assessment on a 7-month-old, they are content sitting on their mothers
lap while sucking on their pacifier. What assessment should you perform first?
a) Eyes, ears, and mouth
, b) Fontanel and head circumference
c) Heart and lungs
d) Reflexes - correct answer ✔✔c) Heart and lungs
Rationale: The child is content and quiet, so the most accurate heart and lung sounds can be
obtained. a) This should be done last because it is the most invasive. b) typically this can be the
start of an exam, however, the child is content and will provide the nurse with more cooperation
and accuracy. d) Reflexes might disturb the child and make auscultation difficult later on.
A one-month old is crying while you are assessing their head and you palpate a slightly bulging
anterior fontanel. What action is indicated?
a) Document the findings.
b) Notify the pediatrician.
c) Check the moro reflex.
d) Time how long the infant cries. - correct answer ✔✔a) document the findings.
Rationale: It is normal for slight bulging while an infant is crying
A patient brings her toddler in for a well child and the nurse notices strabismus and
recommends follow up with an eye specialist. The mother asks what the importance of this is,
what does the nurse explain?
a) Color vision deficit may result.
b) Muscle imbalance can cause loss of vision.
c) Epicanthal folds may develop in the affected eye.
d) Corneal light reflexes may occur symmetrically. - correct answer ✔✔b) Muscle imbalance can
cause loss of vision.
Rationale: loss of vision can occur due to the brain ignoring the visual cues from one eye
a) is an inherited recessive x-linked trait and is evaluated using the Ishihara chart
c) epicanthal folds can partially or completely cover the inner canthi and give a false impression
of malalignment (pseudostrabismus)
d) corneal reflexes are responses to light and accommodation
Study Guide
An infant is brought in for a well-child exam and is asleep. What assessment should the nurse
perform first?
a) inspection
b) palpation
c) percussion
d) auscultation - correct answer ✔✔d) auscultation
Rationale: This is the best time to listen and hear the sounds clearly and this should be done
first.
a and b would require moving the infant and could lead to waking them up and making them
irritable.
You are assessing a 6-month-old infant who smiles, coos, and has strong head lag. What
assessment should the nurse make about this infant's development?
a) These findings are normal for the age.
b) The infant could have cognitive impairment.
c) A developmental/neurologic follow-up evaluation is needed.
d) The parent needs to work with the infant to stop the head lag. - correct answer ✔✔c) A
developmental/neurologic follow-up evaluation is needed.
Rationale: Head lag should be gone by 4 months of age. With persistent head lag this requires
follow-up with a specialist.
When measuring a child's length at or under 24 months, what is the most accurate
measurement?
a) Having the child stand up against the tape measure.
b) Measuring the crown-heel length in prone.
,c) Measuring the crown-heel length in supine.
d) Estimate the length. - correct answer ✔✔c) Measuring the crown-heel length in supine.
How is cranial nerve V (trigeminal nerve) assessed? Select all that apply.
a) ask the child to frown, smile, or make a face
b) stick their tongue out
c) chewing or sucking
d) touching a piece of cotton to the side of the face
e) have the child say "ah" and watch for the uvula and soft palate to rise - correct answer ✔✔c)
chewing or sucking
d) touching a piece of cotton to the side of the face
Rationale: a) Cranial nerve VII (facial nerve)
b) XII (Hypoglossal)
e) IX (glossopharyngeal) AND X (vagus)
You are assessing a preschoolers chest and breathing. What is a normal finding?
a) Respiratory movements are primarily thoracic.
b) Anteroposterior diameter is equal to the transverse diameter.
c) Retractions on inspiration.
d) Movement of the chest wall is symmetrical bilaterally and coordinated with breathing. -
correct answer ✔✔d) Movement of the chest wall is symmetrical bilaterally and coordinated
with breathing.
Rationale: c) rapid respirations, retractions, nasal flaring, and head bobbing may indicate
respiratory difficulty, by preschool years the child's breathing is more coordinated
You are working in the ED when a child is brought in for a cervical neck injury that occurred an
hour prior. Their level of consciousness has been variable since. What is the most essential
assessment to complete?
,a) Perform a fundoscopic examination to identify papilledema.
b) Check pupil reactivity.
c) Perform a doll's head maneuver.
d) Obtain an oculovestibular response. - correct answer ✔✔b) Check pupil reactivity.
Rationale: PERRLA should be performed.
a) papilledema does not present itself until 24-48 hours of unconsciousness and requires
specialty training. c) should not be done a a cervical injury. d) painful, and should not be done
on someone with altering levels of consciousness.
You are preparing to assess an infants lungs sounds but the mother is holding her on her
stomach and she is sleeping. What techniques could be used to get an accurate assessment?
Select all that apply.
a) Gently turn her on her back at the beginning of the assessment.
b) Warm the stethoscope head before placing it on the infant's shirt.
c) Assess the lungs from the apex to the base bilaterally.
d) Identify hyperresonance as normal r/t thin chest walls.
e) Place the infant flat while auscultating the lungs.
f) Auscultate the lung sounds through her back. - correct answer ✔✔c) Assess the lungs from
the apex to the base bilaterally.
d) Identify hyperresonance as normal r/t thin chest walls.
f) Auscultate the lung sounds through her back.
Rationale:
a) Don't want to upset her. b) Should place the head of the stethoscope directly on the skin. e)
elevation of the head while auscultating the lungs allows for a more accurate assessment.
While performing an assessment on a 7-month-old, they are content sitting on their mothers
lap while sucking on their pacifier. What assessment should you perform first?
a) Eyes, ears, and mouth
, b) Fontanel and head circumference
c) Heart and lungs
d) Reflexes - correct answer ✔✔c) Heart and lungs
Rationale: The child is content and quiet, so the most accurate heart and lung sounds can be
obtained. a) This should be done last because it is the most invasive. b) typically this can be the
start of an exam, however, the child is content and will provide the nurse with more cooperation
and accuracy. d) Reflexes might disturb the child and make auscultation difficult later on.
A one-month old is crying while you are assessing their head and you palpate a slightly bulging
anterior fontanel. What action is indicated?
a) Document the findings.
b) Notify the pediatrician.
c) Check the moro reflex.
d) Time how long the infant cries. - correct answer ✔✔a) document the findings.
Rationale: It is normal for slight bulging while an infant is crying
A patient brings her toddler in for a well child and the nurse notices strabismus and
recommends follow up with an eye specialist. The mother asks what the importance of this is,
what does the nurse explain?
a) Color vision deficit may result.
b) Muscle imbalance can cause loss of vision.
c) Epicanthal folds may develop in the affected eye.
d) Corneal light reflexes may occur symmetrically. - correct answer ✔✔b) Muscle imbalance can
cause loss of vision.
Rationale: loss of vision can occur due to the brain ignoring the visual cues from one eye
a) is an inherited recessive x-linked trait and is evaluated using the Ishihara chart
c) epicanthal folds can partially or completely cover the inner canthi and give a false impression
of malalignment (pseudostrabismus)
d) corneal reflexes are responses to light and accommodation
