Chapter 5: Pediatric Assessment

Question 1

When building rapport with a pediatric patient and their caregiver, what is the most appropriate initial step by the nurse?

A. Ask detailed health history questions immediately.
B. Introduce yourself and explain the purpose of the interview.
C. Begin by examining the child for any visible issues.
D. Ask questions only to the caregiver.

Answer 1

B. Introduce yourself and explain the purpose of the interview.

Rationale: Establishing rapport starts with a clear introduction and explanation of the process, fostering trust and communication.

Question 2

Which of the following communication strategies is appropriate when interviewing a family with a cultural background that may differ from the nurse’s?

A. Rely only on closed-ended questions for efficiency.
B. Avoid eye contact when talking to children from all backgrounds.
C. Use an interpreter if needed and assess language preferences.
D. Expect all families to respond in the same way during questioning.

Answer 2

C. Use an interpreter if needed and assess language preferences.

Question 3

A nurse observes a parent who is hesitant to discuss their child’s health concerns and avoids eye contact. What should the nurse consider as a potential reason?

A. The parent is uninterested in their child’s care.
B. Cultural differences may influence communication patterns.
C. The child’s health status is not serious.
D. The parent is distracted by another issue.

Answer 3

B. Cultural differences may influence communication patterns.

Rationale: Cultural norms can greatly influence how people communicate and interact with healthcare providers.

Question 4

When performing a physical assessment on an infant, the nurse should:

A. Conduct invasive procedures first.
B. Keep the infant away from the parent to maintain focus.
C. Use warm hands and a gentle touch.
D. Complete all assessments while the infant is crying.

Answer 4

C. Use warm hands and a gentle touch.

Rationale: Gentle handling and warm hands promote infant comfort and relaxation, making assessments more effective.

Question 5

The posterior fontanelle in infants typically closes by what age?

A. 2-3 months
B. 4-6 months
C. 12 months
D. 18 months

Answer 5

A. 2-3 months

Rationale: The posterior fontanelle generally closes between 2 and 3 months of age.

Question 6

When assessing the skin of a pediatric patient, the nurse notices a linear skin lesion. Which condition could this finding indicate?

A. Ringworm
B. Poison Ivy
C. Chickenpox
D. Urticaria

Answer 6

B. Poison Ivy

Rationale: A linear lesion often results from contact dermatitis, such as poison ivy, which commonly presents in this distribution.

Question 7

In a child under two years old, what is the preferred method of measuring height?

A. Using a standing scale
B. Measuring board in a recumbent position
C. Estimation based on parental height
D. Head circumference assessment only

Answer 7

B. Measuring board in a recumbent position

Rationale: For children under two years, length is measured using a measuring board while lying flat for accuracy.

Question 8

What is a key consideration when conducting an eye examination in a young child?

A. Use bright lights to check pupil response.
B. Avoid explaining the procedure to avoid scaring the child.
C. Ignore any asymmetry in the child’s eye movements.
D. Assess extraocular movements using an object held about 12 inches away.

Answer 8

D. Assess extraocular movements using an object held about 12 inches away.

Question 9

A nurse is assessing the head circumference of an infant. Which of the following would indicate a normal finding?

A. Head circumference is larger than chest circumference in infants under 12 months.
B. Head circumference stops increasing after 4 months.
C. Anterior fontanelle is completely closed by 8 months of age.
D. The suture lines of the skull are fused at birth.

Answer 9

A. Head circumference is larger than chest circumference in infants under 12 months.

Rationale: For infants under 12 months, head circumference is normally larger than chest circumference, reflecting ongoing brain growth.

Question 10

When performing a psychosocial assessment on a school-aged child, which factor is least likely to be relevant?

A. Birth history
B. School performance and peer relationships
C. Financial stability of the family
D. Home environment and living conditions

Answer 10

A. Birth history

Rationale: While birth history can be relevant in certain health contexts, school-aged psychosocial assessments focus more on current social, academic, and environmental factors.

Question 11

A nurse needs to assess the development of fine motor skills in a toddler. Which action would best indicate appropriate development?

A. Walking unassisted for a short distance
B. Stringing large beads or building a tower of blocks
C. Jumping with both feet off the ground
D. Engaging in parallel play with peers

Answer 11

B. Stringing large beads or building a tower of blocks

Rationale: Fine motor skills in toddlers are demonstrated through precise hand movements, such as building with blocks or stringing objects.

Question 12

A preschool-aged child refuses to have a blood pressure reading done. What strategy should the nurse use to facilitate cooperation?

A. Forcefully proceed with the procedure
B. Explain that it will not hurt and perform it quickly
C. Use a game or role-play, such as pretending to check a toy’s “arm” first
D. Ask the parents to hold the child down

Answer 12

C. Use a game or role-play, such as pretending to check a toy’s “arm” first

Rationale: Preschoolers respond well to play and imagination, making this approach effective for reducing anxiety and gaining cooperation.

Question 13

A nurse observes ecchymosis in unusual areas on a non-mobile infant. Which action is the priority?

A. Document findings and monitor for changes.
B. Assume bruising is related to common accidents.
C. Ask the parent to explain the cause of each bruise.
D. Report findings to the appropriate child protective services.

Answer 13

D. Report findings to the appropriate child protective services.

Rationale: Unusual bruising in non-mobile infants may indicate abuse, warranting immediate protective intervention.

Question 14

A 4-year-old child presents with a maculopapular rash and a fever. Which type of lesion is this?

A. Bulla
B. Nodule
C. Patch
D. Macule and papule combination

Answer 14

D. Macule and papule combination

Rationale: A maculopapular rash includes both flat spots (macules) and raised bumps (papules) and is characteristic of certain viral illnesses.

Question 15

The anterior fontanelle typically remains palpable until what age?

A. 2-3 months
B. 6-9 months
C. 12-18 months
D. 24 months

Answer 15

C. 12-18 months

Question 16

Which of the following assessment findings would be concerning in a 3-year-old child during a physical exam?

A. Occasional temper tantrums
B. Refusal to share toys with peers
C. Non-intelligible speech to strangers
D. Consistent inability to run or climb stairs

Answer 16

D. Consistent inability to run or climb stairs

Rationale: By age 3, gross motor development typically includes the ability to run and climb stairs, and a lack of these abilities may indicate developmental delay.

Question 17

Which type of lesion is characterized by an irregular, elevated area of edematous skin, often associated with urticaria or allergic reactions?

A. Vesicle
B. Papule
C. Wheal
D. Tumor

Answer 17

C. Wheal

Rationale: Wheals are raised, often irregular, areas of skin edema commonly seen in allergic reactions.

Question 18

When assessing an adolescent for health status, which aspect is crucial to include due to its unique influence on this age group?

A. Nutritional status
B. Parental concerns about milestones
C. Home environment stability only
D. Psychosocial status, including HEEADSSS screening (Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, Safety)

Answer 18

D. Psychosocial status, including HEEADSSS screening (Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Depression, Safety)

Rationale: HEEADSSS screening is tailored for adolescents, addressing key factors that impact their health and wellbeing

Question 19

When conducting a cover-uncover eye test in a pediatric patient, a movement of the uncovered eye indicates what?

A. Normal ocular alignment
B. Muscle weakness in the covered eye
C. Proper functioning of all cranial nerves
D. Lack of visual tracking capability

Answer 19

B. Muscle weakness in the covered eye

Rationale: Movement of the uncovered eye during this test suggests that it had been compensating for misalignment or muscle weakness.

Question 20

A nurse finds that a child has a hyperpigmented patch greater than 1 cm in diameter. What type of lesion is this classified as?

A. Macule
B. Patch
C. Tumor
D. Nodule

Answer 20

B. Patch

Rationale: A patch is a larger, flat, nonpalpable lesion compared to a macule.

Question 21

During a routine health history interview with a caregiver and a child, the nurse notices the parent frequently looks away and seems anxious when discussing the child’s health issues. What is the best initial response from the nurse?

A. Document the caregiver’s behavior without comment.
B. Change the subject to something unrelated to the child’s health.
C. Ask directly about the caregiver’s concerns or if they need more support.
D. Assume the caregiver does not have relevant information.

Answer 21

C. Ask directly about the caregiver’s concerns or if they need more support.

Rationale: Directly addressing the observed behavior in a supportive manner may uncover underlying issues or anxieties, building trust and promoting honest communication.

Question 22

A nurse uses open-ended questions during a pediatric health interview. Which of the following is an example of this technique?

A. “Did your child have breakfast this morning?”
B. “How would you describe your child’s eating habits?”
C. “Does your child play with friends often?”
D. “Have you noticed any rashes on your child?”

Answer 22

B. “How would you describe your child’s eating habits?”

Rationale: Open-ended questions invite elaboration, encouraging more detailed and comprehensive responses from caregivers.

Question 23

In facilitating an examination for a toddler, which strategy would help reduce their anxiety?

A. Conduct the most invasive part first to get it over with.
B. Offer the child no choices during the exam.
C. Allow the child to hold a security object and offer choices when possible.
D. Separate the child from the parent to minimize distractions

Answer 23

C. Allow the child to hold a security object and offer choices when possible.

Rationale: Offering a sense of control and comfort, such as a security object, helps reduce anxiety and increases cooperation in toddlers.

Question 24

A nurse assessing an infant notices a large fluid-filled blister on the forearm. How should this lesion be classified?

A. Vesicle
B. Bulla
C. Wheal
D. Pustule

Answer 24

B. Bulla

Rationale: A bulla is a fluid-filled lesion larger than 1 cm in diameter, as seen in this scenario.

Question 25

Which of the following factors is least likely to impact a child’s developmental status?

A. Gross and fine motor milestones
B. Cognitive abilities and academic performance
C. Current medications and their effects
D. Parental education level only

Answer 25

D. Parental education level only

Rationale: While parental education can play a role, it is not a sole determinant; many other factors, such as motor milestones, cognitive abilities, and medications, directly impact development.

Question 26

When conducting an anthropometric measurement of a pediatric patient, which step is necessary for accuracy?

A. Weighing infants with clothing on
B. Using a stadiometer for children over 2 years old
C. Measuring height while the child is seated
D. Ignoring head circumference after 12 months of age

Answer 26

B. Using a stadiometer for children over 2 years old

Rationale: Children over the age of 2 should have height measured standing with a stadiometer for accurate growth assessment.

Question 27

A 7-year-old child has bruises on the shins, forehead, and lower arms. What should the nurse consider?

A. These bruises are consistent with normal play injuries.
B. The bruises are a potential indicator of abuse.
C. The nurse should immediately contact child protective services.
D. These findings are never normal in children.

Answer 27

A. These bruises are consistent with normal play injuries.

Rationale: Bruises on the shins, forehead, and arms are common sites for accidental injuries in active, walking children.

Question 28

To assess for cranial nerve function during a pediatric eye exam, which procedure should the nurse perform?

A. Palpating the fontanelles for abnormalities
B. Observing for the sunset sign
C. Testing extraocular movements with a penlight
D. Measuring head circumference

Answer 28

C. Testing extraocular movements with a penlight

Rationale: Testing extraocular movements assesses cranial nerves III, IV, and VI by having both eyes track an object together.

Question 29

Which finding on skin assessment would require further investigation in a child?

A. Freckles evenly distributed on the arms
B. A macule larger than 1 cm without change over time
C. Bruises of various stages of healing on the back
D. Mild dry skin during winter months

Answer 29

C. Bruises of various stages of healing on the back

Rationale: Bruises of different ages, especially in unusual locations like the back, may indicate trauma or abuse.

Question 30

During a developmental screening of a 2-year-old, which gross motor milestone would be expected?

A. Drawing a recognizable circle
B. Walking up and down stairs with assistance
C. Catching a small ball
D. Pedaling a tricycle

Answer 30

B. Walking up and down stairs with assistance

Rationale: By age 2, a child is typically able to walk up and down stairs with assistance.

Question 31

Which of the following is true regarding the inspection of an infant’s head and fontanelles?

A. The posterior fontanelle is usually open until 18 months.
B. Anterior fontanelle closure typically occurs around 2-3 months.
C. Sutures are usually fully fused by 6 months of age.
D. Significant asymmetry or bulging fontanelles should be further evaluated.

Answer 31

D. Significant asymmetry or bulging fontanelles should be further evaluated.

Rationale: Significant asymmetry or bulging may indicate increased intracranial pressure or another concerning condition.

Question 32

A nurse caring for an adolescent is concerned about their reluctance to discuss health issues in front of parents. What is the best approach?

A. Continue the discussion with the parent present.
B. Offer to have a private conversation with the adolescent.
C. Ask parents to answer questions on behalf of the adolescent.
D. Assume the adolescent has no relevant issues to discuss.

Answer 32

B. Offer to have a private conversation with the adolescent.

Rationale: Ensuring privacy respects the adolescent’s need for confidentiality and may encourage open communication.

Question 33

Which of the following skin conditions would be classified as a secondary lesion?

A. Macule
B. Vesicle
C. Scar
D. Wheal

Answer 33

C. Scar

Rationale: Secondary lesions include scars, which result from primary lesions due to infection, irritation, or delayed healing.

Question 34

During a pediatric health assessment, the nurse notices that the child’s palpebral fissures have an upward slant. What condition might this indicate?

A. Down syndrome
B. Normal variation
C. Turner syndrome
D. Cranial nerve palsy

Answer 34

A. Down syndrome

Rationale: An upward slant of the palpebral fissures is commonly associated with Down syndrome.

Question 35

To ensure accurate anthropometric measurements in a child, which of the following is required?

A. Measuring weight with diapers and clothing on
B. Using a consistent method and equipment for repeated measures
C. Ignoring skinfold thickness measurements
D. Only measuring height in children over 5 years old

Answer 35

B. Using a consistent method and equipment for repeated measures

Rationale: Consistency in measurement methods and equipment is crucial for tracking growth and ensuring data accuracy.