McKinney - TEST BANK!!! Physical Assessment of Children
1. Physical Assessment of Children
1. The nurse percussing over an empty stomach expects to hear which
sound?
a. Tympany
b. Resonance
c. Flatness
d. Dullness: ANS: A
Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts
such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound
elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-
intensity sound elicited by percussing over solid masses such as bone or muscle.
Dullness is a medium-pitched, medium-intensity sound elicited when percussing
over high-density structures such as the liver.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 720 | Box 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. Physical Assessment of Children
2. The nurse is admitting a toddler to the pediatric infectious disease unit.
What is the single most important component of the child's physical
examination?
a. Assessment of heart and lungs
b. Measurement of height and weight
c. Documentation of parental concerns
d. Obtaining an accurate history: ANS: D
An accurate history is most helpful in identifying problems and potential problems.
Heart and lung assessment is not as important as an accurate history. A single
measurement of height and weight is not as significant as determining growth over
time. The child's growth pattern can be elicited from the history. Documentation of
parental concerns is not as relevant to the physical examination as an accurate
history in this case.
PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 720 | Box 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
, McKinney - TEST BANK!!! Physical Assessment of Children
3. Physical Assessment of Children
3. In which section of the health history should the nurse record that the
parent brought the infant to the clinic today because of frequent diarrhea?
a. Review of systems
b. Chief complaint
c. Lifestyle and life patterns
d. Health history: ANS: B
The chief complaint is documented using the child's or parent's words for the reason
the child was brought to the health care center. The review of systems includes
health functions of body systems. Lifestyle and life patterns include the child's
interaction with the social, psychological, physical, and cultural environment. Health
history includes birth history, growth and development, common childhood
illnesses, immunizations, hospitalizations, injuries, and allergies.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 721 | Box 33.4 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
4. Physical Assessment of Children
4. The nurse assesses a child's oculomotor, trochlear, and abducent nerves
by using which technique?
a. Assessing the six cardinal gazes
b. Identification of common odors
c. Having child bite on a tongue blade
d. Ask child to shrug against resistance: ANS: A
Using the six cardinal gazes the nurse assesses the oculomotor, trochlear, and
abducent nerves. Odors are detected by the olfactory nerve. Biting on tongue
blade assesses the trigeminal nerve. Shrugging against resistance assesses the
accessory nerve.
PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 745 | Table 33.4 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
5. Physical Assessment of Children
, McKinney - TEST BANK!!! Physical Assessment of Children
5. The nurse is performing a comprehensive physical examination on a young
child in the hospital. At what age can the nurse expect a child's head and
chest circumferences to be almost equal?
a. Birth
b. 6 months
c. 1 year
d. 3 years: ANS: C
Head and chest measurements are almost equal at 1 year of age.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 724 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
6. Physical Assessment of Children
6. An 8-year-old girl asks the nurse how the blood pressure apparatus
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.
PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 719 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
7. Physical Assessment of Children
7. Which chart should the nurse use to assess the visual acuity of
an 8-year-old child?
a. Lea chart
1. Physical Assessment of Children
1. The nurse percussing over an empty stomach expects to hear which
sound?
a. Tympany
b. Resonance
c. Flatness
d. Dullness: ANS: A
Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts
such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound
elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-
intensity sound elicited by percussing over solid masses such as bone or muscle.
Dullness is a medium-pitched, medium-intensity sound elicited when percussing
over high-density structures such as the liver.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 720 | Box 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. Physical Assessment of Children
2. The nurse is admitting a toddler to the pediatric infectious disease unit.
What is the single most important component of the child's physical
examination?
a. Assessment of heart and lungs
b. Measurement of height and weight
c. Documentation of parental concerns
d. Obtaining an accurate history: ANS: D
An accurate history is most helpful in identifying problems and potential problems.
Heart and lung assessment is not as important as an accurate history. A single
measurement of height and weight is not as significant as determining growth over
time. The child's growth pattern can be elicited from the history. Documentation of
parental concerns is not as relevant to the physical examination as an accurate
history in this case.
PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 720 | Box 33.1 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
, McKinney - TEST BANK!!! Physical Assessment of Children
3. Physical Assessment of Children
3. In which section of the health history should the nurse record that the
parent brought the infant to the clinic today because of frequent diarrhea?
a. Review of systems
b. Chief complaint
c. Lifestyle and life patterns
d. Health history: ANS: B
The chief complaint is documented using the child's or parent's words for the reason
the child was brought to the health care center. The review of systems includes
health functions of body systems. Lifestyle and life patterns include the child's
interaction with the social, psychological, physical, and cultural environment. Health
history includes birth history, growth and development, common childhood
illnesses, immunizations, hospitalizations, injuries, and allergies.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 721 | Box 33.4 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
4. Physical Assessment of Children
4. The nurse assesses a child's oculomotor, trochlear, and abducent nerves
by using which technique?
a. Assessing the six cardinal gazes
b. Identification of common odors
c. Having child bite on a tongue blade
d. Ask child to shrug against resistance: ANS: A
Using the six cardinal gazes the nurse assesses the oculomotor, trochlear, and
abducent nerves. Odors are detected by the olfactory nerve. Biting on tongue
blade assesses the trigeminal nerve. Shrugging against resistance assesses the
accessory nerve.
PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 745 | Table 33.4 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
5. Physical Assessment of Children
, McKinney - TEST BANK!!! Physical Assessment of Children
5. The nurse is performing a comprehensive physical examination on a young
child in the hospital. At what age can the nurse expect a child's head and
chest circumferences to be almost equal?
a. Birth
b. 6 months
c. 1 year
d. 3 years: ANS: C
Head and chest measurements are almost equal at 1 year of age.
PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 724 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
6. Physical Assessment of Children
6. An 8-year-old girl asks the nurse how the blood pressure apparatus
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.
PTS: 1 DIF: Cognitive Level: Application/Applying
REF: p. 719 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
7. Physical Assessment of Children
7. Which chart should the nurse use to assess the visual acuity of
an 8-year-old child?
a. Lea chart
