Exam Review Questions (class lecture) Flashcards
Place the nursing assessments of a toddler in the best order.
1.) Examination of eyes, ears, & throat
2.) Auscultation of chest
3.) Palpation of abdomen
4.) Developmental assessment
4, 2, 3, 1
- 4.) Developmental Assessment
- 2.) Auscultation of chest
- 3.) Palpation of abdomen
- 1.) Examination of eyes, ears, & throat
In a toddler, it is usually best to go from least invasive to most invasive in order to build trust & cooperation
The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport & elicit an accurate response from the family?
a.) “Does any member of your family have a history of asthma, heart disease, or diabetes?”
b.) “Hello, I would like to talk with you & get some information on you and your child”.
c.) “Tell me about the concerns that brought you to the clinic today”.
d.) “You will need to fill out these forms; make sure that the information is as complete as possible”.
c.) “Tell me about the concerns that brought you to the clinic today.
Asking the parents to talk aobut their concerns is an open-ended question & one which is more likely to establish rapport & an understanding of the parent’s perceptions.
A new mother is worried about a “soft spot” on the top of her newborn infant’s head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close?
a.) 2 - 3 months
b.) 6 - 9 months
c.) 12 - 18 months
d.) approximately 2 years
c.) 12 - 18 months
The *anterior fontanel *is located at the top of the head. As the infant grows, the suture lines begin to fuse, & the anterior fontanel closes as 12-18 months of age
A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? (Select all that apply)
a.) Wheezing
b.) Increased tactile fremitus
c.) Decreased tactile fremitus
d.) Bronchophony
a.) Wheezing
c.) Decreased tactile fremitus
- Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition persistent with ashtma exacerbations.
- Decrease in Tactile Fremitus due to air trapping in the lungs that occurs in ashtma
During the nurse’s initial assessment of a school-aged child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. Which action by the nurse is most appropriate?
a.) Administer prescribed analgesic.
b.) Ask the child’s parent’s if they think the child is hurting.
c.) Reassess the child in 15 minutes to see if the pain rating has changed.
d.) Do nothing, since the child appears to be resting.
a.) Administer the analgesic
The nurse is caring for a toddler patient in the post-operative period. Which pain assessment tool is most appropriate for this patient?
a.) FLACC Behavioral Pain Assessment Scale
b.) FACES pain scale
c.) Oucher scale
d.) Poker-chip tool
a.) FLACC Behavioral Pain Assessment Scale
The FLACC scale is an appropriate tool for infants & young children who cannot self-report pain.
A hospitalized toddler-age patient needs to have an IV re-started. The child begins to cry when carried into the treatment room by the mother. Which nursing diagnosis is most appropriate?
a.) Ineffective individual coping related to an invasive procedure
b.) Anxiety related to anticipated painful procedure
c.) Fear related to the unfamiliar environment
d.) knowledge deficit about the procedure
b.) Anxiety r/t anticipated painful procedure
At this age, the child is not old enough to understand the need for an IV infusion. THe stem indicates that the child has been through this painful procedure before, & his reaction to entering the treatment room is based on anticipation fo repeat discomfort.
The nurse is caring for a child who has a long leg cast. The child complains of increasing pain in the toes of the casted foot. Which initial action by the nurse is the most appropriate?
a.) Call the healthcare provider to report increasing pain.
b.) Administer pain medication.
c.) Reposition the child in bed.
d.) Check to see if the cast is too tight.
d.) Check to see if the cast is too tight
The nurse’s initial action is to assess for external factors that mgiht be causing pain
The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is most appropriate?
a.) Escort the parents to the waiting room & assure them that they can see the child soon.
b.) Allow the parents tot stay with the child.
c.) Ask the physician if the parents can stay with the child.
d.) Tell the parents that they do not need to stay with the child.
b.) Allow the parents to stay with the child
A preschool-age client is seen in the clinic for a sore throat. In this child’s mind, what is the most likely causative agent for the sore throat?
a.) Was exposed to someone else with a sore throat.
b.) Did not eat the right foods.
c.) Yelled at his brother.
d.) Did not take his vitamins
c.) Yelled at his brother
The nurse is planning educational interventions to reduce the incidence of the number one cause of mortality in children ages 1-4. Recognizing the developmental needs of this age group, the nurse would focus the session on which topic?
a.) Recognition of congenital malformation.
b.) Safe sleeping practices.
c.) Child abuse prevention.
d.) Car seat use
d.) Car seat use
MVCs are one of the most common causes of unintentional injury, & the most common cause of death in this age group (1-4 years old)
The nurse assesses parenting styles in a family by asking how situations that require setting limits are handled. Responses indicate that limits are set consistently, and an atmosphere of open discussion is evident. Which parenting style would the nurse identify from this description?
a.) Permissive
b.) Indifferent
c.) Authoritative
d.) Authoritarian
c.) Authoritative
Authoritative parents set appropriate limits while establishing an atmosphere of open discussion, thus promoting developmental integrity & trust.
A 1-year-old child is scheduled for a routine exam at the pediatric clinic. The child’s birth weight was 8 lbs. 2 oz. The child now weighs 18 pounds, 4 ounces. How would the nurse interpret this?
a.) Below the expected weight.
b.) Approrpriate for the child’s age.
c.) Above the expected weight.
d.) Individualized, and thus unpredictable
a.) Below the expected weight
The birth weight usually doubles by 5 months & triples by the end of the first year.
- The child should weight at least 24 lbs 6 oz.
The nurse notes that a 6-month-old has significant head lag when an attempt is made to pull the infant to a sitting position. Based on this assessment, the nurse recognizes which of the following?
a.) The infant has some degree of mental retardation.
b.) The infant needs further assessment & evaluation.
c.) The baby is developing normally.
d.) The child has been neglected by the parents.
b.) The infant needs further assessment
Head lag should not be present in a 6 month old (there should be no head lag between 4 & 6 months of age). The nurse cannot conclude that the child has been neglected or has some degree of mental retardation based on head lag alone.
The nurse observes two children playing side-by-side. Of what age group is this behavior characteristic?
a.) Infant
b.) Toddler
c.) Preschooler
d.) School age
b.) Toddler
