Chapter 29 Communication, History and Physical Assessment PDF

Chapter 29: Communication, History, and Physical Assessment MULTIPLE CHOICE 1. The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce himself or herself. c. Explain the purpose of the interview. b. Make the family comforta...

Chapter 29: Communication, History, and Physical Assessment MULTIPLE CHOICE 1. The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce himself or herself. c. Explain the purpose of the interview. b. Make the family comfortable. d. Give an assurance of privacy. ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview the nurse should include general conversation to help make the family feel at ease. Next, the purpose of the interview and the nurses role should be clarified. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality. PTS: 1 DIF: Cognitive Level: Application REF: 771 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 2. Which action is most likely to encourage parents to talk about their feelings related to their childs illness? a. Be sympathetic. c. Use open-ended questions. b. Use direct questions. d. Avoid periods of silence. ANS: C Closed-ended questions should be avoided when attempting to elicit parents feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. PTS: 1 DIF: Cognitive Level: Application REF: 773 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 3. What is the single most important factor to consider when communicating with children? a. The childs physical condition b. The presence or absence of the childs parent c. The childs developmental level Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material d. The childs nonverbal behaviors ANS: C The nurse must be aware of the childs developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the childs physical condition is a consideration, developmental level is much more important. The parents presence is important when communicating with young children, but it may be detrimental when speaking with adolescents. Nonverbal behaviors vary in importance based on the childs developmental level. PTS: 1 DIF: Cognitive Level: Comprehension REF: 774 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 4. What is an important consideration for the nurse who is communicating with a very young child? a. Speak loudly, clearly, and directly. b. Use transition objects such as a doll. c. Disguise own feelings, attitudes, and anxiety. d. Initiate contact with the child when the parent is not present. ANS: B Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This facilitates communication with this age child. Speaking loudly, clearly, and directly tends to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children. PTS: 1 DIF: Cognitive Level: Comprehension REF: 775 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 5. When introducing hospital equipment to a preschooler who seems afraid, the nurses approach should be based on which principle? a. The child may think the equipment is alive. b. The child is too young to understand what the equipment does. c. Explaining the equipment will only increase the childs fear. d. One brief explanation is enough to reduce the childs fear. ANS: A Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. The child should be given simple concrete explanations about what the equipment does and how it will feel to the child. Simple, concrete explanations help alleviate the childs fear. The preschooler will need repeated explanations as reassurance. PTS: 1 DIF: Cognitive Level: Analysis REF: 791 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 6. Which age group is most concerned with body integrity? a. Toddler c. School-age child b. Preschooler d. Adolescent ANS: C School-age children have a heightened concern about body integrity. They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggestion of injury. Body integrity is not as important a concern to children in the toddler, preschooler, and adolescent age groups. PTS: 1 DIF: Cognitive Level: Comprehension REF: 776 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 7. 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. A nurse should respond positively to requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. 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 the child can then observe during the procedure. PTS: 1 DIF: Cognitive Level: Comprehension REF: 776 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. When the nurse interviews an adolescent, it is especially important to: a. Focus the discussion on the peer group. Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Allow an opportunity to express feelings. c. Emphasize that confidentiality will always be maintained. d. Use the same type of language as the adolescent. ANS: B Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age group, the focus of the interview should be on the adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently. PTS: 1 DIF: Cognitive Level: Comprehension REF: 776 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 9. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique may be most helpful? a. Suggest that the child keep a diary. b. Suggest that the parent read fairy tales to the child. c. Ask the parent whether the child is always uncommunicative. d. Ask the child to draw a picture. ANS: D Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childs inner self. It would be difficult for a 6-year-old child to keep a diary because the child is most likely learning to read. Reading fairy tales to the child is a passive activity involving the parent and child. It would not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not necessarily uncommunicative. PTS: 1 DIF: Cognitive Level: Application REF: 778 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 10. The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? a. Ask for a detailed listing of symptoms. b. Ask the adolescent, Why did you come here today? c. Use what the adolescent says to determine, in correct medical terminology, what the problem is. Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material d. Interview the parent away from the adolescent to determine the chief complaint. ANS: B The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A listing of symptoms will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him or her to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time. PTS: 1 DIF: Cognitive Level: Application REF: 779 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 11. Where in the health history should the nurse describe all details related to the chief complaint? a. Past history c. Present illness b. Chief complaint d. Review of systems ANS: C The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present. Past history refers to information that relates to previous aspects of the childs health, not to the current problem. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system. PTS: 1 DIF: Cognitive Level: Comprehension REF: 779 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. The nurse is interviewing the mother of an infant. She reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading? a. Birth history c. Chief complaint b. Present illness d. Review of systems ANS: A The birth history refers to information that relates to previous aspects of the childs health, not to the current problem. The mothers difficult delivery and prematurity are important parts of the past history of an infant. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It would not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth. Sequelae such as pulmonary dysfunction would be included. PTS: 1 DIF: Cognitive Level: Comprehension REF: 780 Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are: a. Unnecessary information because the child is age 3 years. b. An important part of the family history. c. An important part of the childs past growth and development. d. An important part of the childs review of systems. ANS: C Information about the attainment of developmental milestones is important to obtain. It provides data about the childs growth and development that should be included in the history. Developmental milestones provide important information about the childs physical, social, and neurologic health. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones. PTS: 1 DIF: Cognitive Level: Comprehension REF: 780 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: a. Ask her, Are you sexually active? b. Ask her, Are you having sex with anyone? c. Ask her, Are you having sex with a boyfriend? d. Ask both the girl and her parent if she is sexually active. ANS: B Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone. PTS: 1 DIF: Cognitive Level: Application REF: 782 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material a. Indicates that they live in poverty. b. Is lacking in protein. c. May provide sufficient amino acids. d. Should be enriched with meat and milk. ANS: C The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that contain this combination of foods. It does not indicate poverty. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth. PTS: 1 DIF: Cognitive Level: Application REF: 785 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 16. Which parameter correlates best with measurements of the bodys total protein stores? a. Height c. Skin-fold thickness b. Weight d. Upper arm circumference ANS: D Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the bodys major protein reserve and is considered an index of the bodys protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the bodys fat content. PTS: 1 DIF: Cognitive Level: Comprehension REF: 790 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 17. An appropriate approach to performing a physical assessment on a toddler is to: a. Always proceed in a head-to-toe direction. b. Perform traumatic procedures first. c. Use minimal physical contact initially. d. Demonstrate use of equipment. ANS: C Parents can remove the childs clothing, and the child can remain on the parents lap. The nurse should use minimal physical contact initially to gain the childs cooperation. The head-to-toe assessment can be done in Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age group. PTS: 1 DIF: Cognitive Level: Comprehension REF: 793 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 18. With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)forage percentile indicates a risk for being overweight? a. 10th percentile c. 85th percentile b. 9th percentile d. 95th percentile ANS: C Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight. PTS: 1 DIF: Cognitive Level: Comprehension REF: 790 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 19. The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that: a. This growth chart should not be used. b. Growth patterns of African-American children are the same as for all other ethnic groups. c. A correction factor is necessary when the NCHS growth chart is used for non-Caucasian ethnic groups. d. The NCHS charts are accurate for U.S. African-American children. ANS: D The NCHS growth charts can serve as reference guides for all racial or ethnic groups. U.S. African Americanchildren were included in the sample population. The growth chart can be used with the perspective that different groups of children have varying normal distributions on the growth curves. No correction factor exists. PTS: 1 DIF: Cognitive Level: Comprehension REF: 791 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. Which tool measures body fat most accurately? a. Stadiometer c. Cloth tape measure Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Calipers d. Paper or metal tape measure ANS: B Calipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made. PTS: 1 DIF: Cognitive Level: Comprehension REF: 795 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 21. By what age do the head and chest circumferences generally become equal? a. 1 month c. 1 to 2 years b. 6 to 9 months d. 2.5 to 3 years ANS: C Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference at ages 1 month and 6 to 9 months. Chest circumference is larger than head circumference at age 2.5 to 3 years. PTS: 1 DIF: Cognitive Level: Comprehension REF: 795 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 22. The earliest age at which a satisfactory radial pulse can be taken in children is: a. 1 year c. 3 years b. 2 years d. 6 years ANS: B Satisfactory radial pulses can be used in children older than 2 years. In infants and young children the apical pulse is more reliable. The radial pulse can be used for assessment at ages 3 and 6 years. PTS: 1 DIF: Cognitive Level: Comprehension REF: 796 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 23. Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face c. Oral mucosa b. Buttocks d. Palms and soles ANS: C Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material conjunctiva. PTS: 1 DIF: Cognitive Level: Comprehension REF: 803 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 24. When palpating the childs cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: 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. Tender lymph nodes do not usually indicate cancer. A scalp infection usually does not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed. PTS: 1 DIF: Cognitive Level: Analysis REF: 805 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 25. The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. The most appropriate action is to: a. Refer for immediate medical evaluation. b. Continue the assessment to determine the cause of neck pain. c. Ask the parent when the childs neck was injured. d. Record head lag on the assessment record and continue the assessment of the child. ANS: A These symptoms indicate meningeal irritation and need immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag. PTS: 1 DIF: Cognitive Level: Analysis REF: 805 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 26. The nurse should expect the anterior fontanel to close at age: a. 2 months c. 6 to 8 months Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. 2 to 4 months d. 12 to 18 months ANS: D Ages 2 through 8 months are too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes at these earlier ages, the child should be referred for further evaluation. PTS: 1 DIF: Cognitive Level: Comprehension REF: 805 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 27. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is: a. A normal finding. b. An abnormal finding; the child needs referral to an ophthalmologist. c. A sign of a possible visual defect; the child needs vision screening. d. A sign of small hemorrhages, which usually resolve spontaneously. ANS: A A brilliant, uniform red reflex is an important normal and expected finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber. PTS: 1 DIF: Cognitive Level: Knowledge REF: 806 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 28. Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? a. 1 month c. 6 to 8 months b. 3 to 4 months d. 12 months ANS: B Binocularity is usually achieved by ages 3 to 4 months. Age 1 month is too young for binocularity. If binocularity is not achieved by 6 months, the child must be observed for strabismus. PTS: 1 DIF: Cognitive Level: Comprehension REF: 806 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 29. The most frequently used test for measuring visual acuity is the: a. Denver Eye Screening test. c. Ishihara vision test. b. Allen picture card test. d. Snellen letter chart. Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: D The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. Single cards (Denverletter E; Allenpictures) are used for children age 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for color vision. PTS: 1 DIF: Cognitive Level: Comprehension REF: 806 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. The nurse is testing an infants visual acuity. By what age should the infant be able to fix on and follow a target? a. 1 month c. 3 to 4 months b. 1 to 2 months d. 6 months ANS: C Visual fixation and following a target should be present by ages 3 to 4 months. Ages 1 to 2 months are too young for this developmental milestone. If the infant is not able to fix and follow by 6 months of age, further ophthalmologic evaluation is needed. PTS: 1 DIF: Cognitive Level: Comprehension REF: 807 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 31. The appropriate placement of a tongue blade for assessment of the mouth and throat is the: a. The center back area of the tongue. c. Against the soft palate. b. The side of the tongue. d. On the lower jaw. ANS: B The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement on the center back area of the tongue elicits the gag reflex. Against the soft palate and on the lower jaw are not appropriate places for the tongue blade. PTS: 1 DIF: Cognitive Level: Comprehension REF: 812 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 32. What type of breath sound is normally heard over the entire surface of the lungs, except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular c. Adventitious b. Bronchial d. Bronchovesicular ANS: A Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate. PTS: 1 DIF: Cognitive Level: Comprehension REF: 815 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 33. What term is used to describe breath sounds that are produced as air passes through narrowed passageways? a. Rubs c. Wheezes b. Rattles d. Crackles ANS: C Wheezes are produced as air passes through narrowed passageways. The sound is similar when the narrowing is caused by exudates, inflammation, spasm, or tumor. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture. PTS: 1 DIF: Cognitive Level: Comprehension REF: 815 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 34. The nurse must assess a childs capillary filling time. This can be accomplished by: a. Inspecting the chest. b. Auscultating the heart. c. Palpating the apical pulse. d. Palpating the skin to produce a slight blanching. ANS: D Capillary filling time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary filling time. PTS: 1 DIF: Cognitive Level: Comprehension REF: 816 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 35. 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 c. Murmur Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. S3, S4 d. Physiologic splitting ANS: C Murmurs are the sounds that are produced in the heart chambers or major arteries from the backand-forth flow of blood. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves, and both are considered normal heart sounds. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding. PTS: 1 DIF: Cognitive Level: Comprehension REF: 818 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 36. The nurse has a 2-year-old boy sit in tailor position during palpation for the testes. The rationale for this position is that: 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. Undescended testes cannot be predictably palpated. Inguinal hernias are not detected by this method. This position is used for inhibiting the cremasteric reflex. Privacy should always be provided for children. PTS: 1 DIF: Cognitive Level: Comprehension REF: 821 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 37. During examination of a toddlers extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: a. Abnormal and requires 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 Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk, not an abnormal Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material finding. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African-American children. PTS: 1 DIF: Cognitive Level: Comprehension REF: 822 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 38. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the fingerto-nose test. The nurse is testing for: a. Deep tendon reflexes. c. Sensory discrimination. b. Cerebellar function. d. Ability to follow directions. ANS: B The finger-to-nose-test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Each sense is tested separately. Although this test enables the nurse to evaluate the childs ability to follow directions, it is used primarily for cerebellar function. PTS: 1 DIF: Cognitive Level: Comprehension REF: 823 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 39. The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as: a. Inappropriate, because of childs age. b. A way to establish rapport. c. Too distracting, when cooperation is important. d. Acceptable, if there is adequate time. ANS: B A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic. PTS: 1 DIF: Cognitive Level: Analysis REF: 778 OBJ: Nursing Process: Communication, Documentation MSC: Client Needs: Psychosocial Integrity 40. The nurse must assess 10-month-old infant. The infant is sitting on the fathers lap and appears to be afraid of the nurse and of what may happen next. Which initial action by the nurse would be most appropriate? a. Initiate a game of peek-a-boo. Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material b. Ask the father to place the infant on the examination table. c. Undress the infant while he is still sitting on his fathers lap. d. Talk softly to the infant while taking him from his father. ANS: A Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done while the child is on the fathers lap. The nurse should have the father undress the child as needed for the examination. PTS: 1 DIF: Cognitive Level: Application REF: 777 OBJ: Nursing Process: Communication, Documentation MSC: Client Needs: Psychosocial Integrity 41. During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurses most appropriate action? a. Teach the parents appropriate exercises. b. Recheck head control at the next visit. c. Refer the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open. ANS: C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated. PTS: 1 DIF: Cognitive Level: Application REF: 805 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 42. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff (Select all that apply)? a. The cuff is labeled toddler. b. The cuff bladder width is approximately 40% of the circumference of the upper arm. c. The cuff bladder length covers 80% to 100% of the circumference of the upper arm. Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material d. The cuff bladder covers 50% to 66% of the length of the upper arm. ANS: B, C Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. This size cuff will most accurately reflect measured radial artery pressure. The name of the cuff is a representative size that may not be suitable for any individual child. Choosing a cuff by limb circumference more accurately reflects arterial pressure than choosing a cuff by length. PTS: 1 DIF: Cognitive Level: Comprehension REF: 800 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 43. Which data would be included in a health history (Select all that apply)? a. Review of systems b. Physical assessment c. Sexual history d. Growth measurements e. Nutritional assessment f. Family medical history ANS: A, C, E, F The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history. Physical assessment and growth measurements are components of the physical examination. PTS: 1 DIF: Cognitive Level: Application REF: 779 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 44. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis (Select all that apply)? a. Complaints of a sore back b. Asymmetry of the shoulders c. An uneven hemline d. Inability to bend at the waist e. Unequal waist angles Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material ANS: B, C, E The assessment findings associated with scoliosis include asymmetry of the shoulder and hips, trouser pant leg length appearing shorter on one side, or an uneven hemline on a skirt, indicating unequal leg length. The child may also complain of a sore back. The child is able to bend at the waist adequately. PTS: 1 DIF: Cognitive Level: Application REF: 822 OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance 45. A nurse is performing an assessment on a school-age child. Which findings suggest the child is receiving an excess of vitamin A (Select all that apply)? a. Delayed sexual development b. Edema c. Pruritus d. Jaundice e. Paresthesia ANS: A, C, D Excess vitamin A can cause delayed sexual development, pruritus, and jaundice. Edema is seen with excess sodium. Paresthesia occurs with excess riboflavin. PTS: 1 DIF: Cognitive Level: Application REF: 787 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 46. A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter (Select all that apply)? a. Elicit one answer at a time. b. Interrupt the interpreter if the response from the family is lengthy. c. Comments to the interpreter about the family should be made in English. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family. ANS: A, D, E When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: Do you Downloaded by: scrublife1985 | [email protected] Distribution of this document is illegal Want to earn $103 per month? Downloaded by Craig Cman ([email protected]) lOMoARcPSD|15450111 Stuvia.com - The Marketplace to Buy and Sell your Study Material have pain? rather than Do you have any pain, tiredness, or loss of appetite? Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English. PTS: 1 DIF: Cognitive Level: Application REF: 774 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maint