Unit C-Physical Assessment of the Adult, Child, and Family

Question 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.
b. Make the family comfortable.
c. Explain the purpose of the interview.
d. Give an assurance of privacy.

Answer 1

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 nurse’s 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.

Question 2

Which action is most likely to encourage parents to talk about their feelings related to their
child’s illness?
a. Be sympathetic.
b. Use direct questions.
c. Use open-ended questions.
d. Avoid periods of silence.

Answer 2

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.

Question 3

What is the single most important factor to consider when communicating with children?

a. The child’s physical condition
b. The presence or absence of the child’s parent
c. The child’s developmental level
d. The child’s nonverbal behaviors

Answer 3

ANS: C
The nurse must be aware of the child’s developmental stage to engage in effective
communication. The use of both verbal and nonverbal communication should be appropriate
to the developmental level. Although the child’s 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 child’s developmental
level.

Question 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.

Answer 4

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.

Question 5

Which age-group is most concerned with body integrity?

a. Toddler
b. Preschooler
c. School-age child
d. Adolescent

Answer 5

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

Question 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.

Answer 6

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.

Question 7

When the nurse interviews an adolescent, it is especially important to:

a. focus the discussion on the peer group.
b. allow an opportunity to express feelings.
c. emphasize that confidentiality will always be maintained.
d. use the same type of language as the adolescen

Answer 7

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.

Question 8

The nurse is taking a health history on an adolescent. Which 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.
d. Interview the parent away from the adolescent to determine the chief complaint.

Answer 8

ANS: B
The chief complaint is the specific reason for the child’s 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.

Question 9

Where in the health history should the nurse describe all details related to the chief complaint?

a. Past history
b. Chief complaint
c. Present illness
d. Review of systems

Answer 9

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 child’s health,
not to the current problem. The chief complaint is the specific reason for the child’s 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.

Question 10

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
b. Present illness
c. Chief complaint
d. Review of systems

Answer 10

ANS: A
The birth history refers to information that relates to previous aspects of the child’s health, not
to the current problem. The mother’s 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 child’s 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

Question 11

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 child’s past growth and development.
d. an important part of the child’s review of systems.

Answer 11

ANS:C
Information about the attainment of developmental milestones is important to obtain. It
provides data about the child’s growth and development that should be included in the history.
Developmental milestones provide important information about the child’s 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.

Question 12

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.

Answer 12

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.

Question 13

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:
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.

Answer 13

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.

Question 14

Which parameter correlates best with measurements of the body’s total protein stores?

a. Height
b. Weight
c. Skin-fold thickness
d. Upper arm circumference

Answer 14

ANS: D
Upper arm circumference is correlated with measurements of total muscle mass. Muscle
serves as the body’s major protein reserve and is considered an index of the body’s protein
stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional
status. Skin-fold thickness is a measurement of the body’s fat content.

Question 15

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.

Answer 15

ANS: C
Parents can remove the child’s clothing, and the child can remain on the parent’s lap. The
nurse should use minimal physical contact initially to gain the child’s cooperation. The
head-to-toe assessment can be done in 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.

Question 16

With the National Center for Health Statistics (NCHS) criteria, which body mass index
(BMI)–for-age percentile indicates a risk for being overweight?
a. 10th percentile
b. 9th percentile
c. 85th percentile
d. 95th percentile

Answer 16

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.

Question 17

Which tool measures body fat most accurately?

a. Stadiometer
b. Calipers
c. Cloth tape measure
d. Paper or metal tape measure

Answer 17

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.

Question 18

By what age do the head and chest circumferences generally become equal?

a. 1 month
b. 6 to 9 months
c. 1 to 2 years
d. 2.5 to 3 years

Answer 18

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

Question 19

The earliest age at which a satisfactory radial pulse can be taken in children is:

a. 1 year.
b. 2 years.
c. 3 years.
d. 6 years

Answer 19

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

Question 20

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

a. Face
b. Buttocks
c. Oral mucosa
d. Palms and soles

Answer 20

ANS: C
Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are
in the mouth or conjunctiva

Question 21

When palpating the child’s 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.

Answer 21

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.

Question 22

The nurse has just started assessing a young child who is febrile and appears very ill. There is
hyperextension of the child’s 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 child’s neck was injured.
d. record “head lag” on the assessment record and continue the assessment of the
child.

Answer 22

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.

Question 23

The nurse should expect the anterior fontanel to close at age:

a. 2 months.
b. 2 to 4 months.
c. 6 to 8 months.
d. 12 to 18 months.

Answer 23

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.

Question 24

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.

Answer 24

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.

Question 25

Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is
normally present by what age?
a. 1 month
b. 3 to 4 months
c. 6 to 8 months
d. 12 months

Answer 25

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

Question 26

The most frequently used test for measuring visual acuity is the:

a. Denver Eye Screening test.
b. Allen picture card test.
c. Ishihara vision test.
d. Snellen letter chart.

Answer 26

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 (Denver—letter E; Allen—pictures) 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.

Question 27

The nurse is testing an infant’s visual acuity. By what age should the infant be able to fix on
and follow a target?
a. 1 month
b. 1 to 2 months
c. 3 to 4 months
d. 6 months

Answer 27

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:

Question 28

The appropriate placement of a tongue blade for assessment of the mouth and throat is the:

a. the center back area of the tongue.
b. the side of the tongue.
c. against the soft palate.
d. on the lower jaw.

Answer 28

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.

Question 29

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
b. Bronchial
c. Adventitious
d. Bronchovesicular

Answer 29

ANS: A
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.

Question 30

Which term is used to describe breath sounds that are produced as air passes through
narrowed passageways?
a. Rubs
b. Rattles
c. Wheezes
d. Crackles

Answer 30

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.

Question 31

The nurse must assess a child’s capillary refilling 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

Answer 31

ANS: D
Capillary refilling 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.

Question 32

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
b. S3, S4
c. Murmur
d. Physiologic splitting

Answer 32

ANS: C
Murmurs are the sounds that are produced in the heart chambers or major arteries from the
back-and-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

Question 33

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.

Answer 33

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.

Question 34

During examination of a toddler’s 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

Answer 34

ANS: D
Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk, not
an abnormal 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.

Question 35

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the
“finger-to-nose” test. The nurse is testing for:
a. deep tendon reflexes.
b. cerebellar function.
c. sensory discrimination.
d. ability to follow directions.

Answer 35

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 child’s ability to follow directions, it is
used primarily for cerebellar function.

Question 36

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 child’s age.
b. a way to establish rapport.
c. too distracting, when cooperation is important.
d. acceptable, if there is adequate time

Answer 36

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.

Question 37

During a routine health assessment, the nurse notes that an 8-month-old infant has significant
head lag. Which is the nurse’s 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.

Answer 37

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.

Question 38

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his
24-month 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.
d. The cuff bladder covers 50% to 66% of the length of the upper arm.

Answer 38

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.

Question 39

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

Answer 39

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.

Question 40

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

Answer 40

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.

Question 41

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

Answer 41

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.

Question 42

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.

Answer 42

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 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.

Question 43

Kyle, age 6 months, is brought to the clinic. His parent says, “I think he hurts. He cries and
rolls his head from side to side a lot.” This most likely suggests which feature of pain?
a. Type
b. Severity
c. Duration
d. Location

Answer 43

ANS: D
The child is displaying a local sign of pain. Rolling the head from side to side and pulling at
ears indicate pain in the ear. The child’s behavior indicates the location of the pain. The
behavior does not provide information about the type, severity, or duration

Question 44

Physiologic measurements in children’s pain assessment are:

a. the best indicator of pain in children of all ages.
b. essential to determine whether a child is telling the truth about pain.
c. of most value when children also report having pain.
d. of limited value as sole indicator of pain.

Answer 44

ANS: D
Physiologic manifestations of pain may vary considerably and may not provide a consistent
measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear,
anxiety, or anger also indicate pain. In chronic pain the body adapts, and these signs decrease
or stabilize. These signs are of limited value and must be viewed in the context of a
pain-rating scale, behavioral assessment, and parental report. When the child states that pain
exists, it does. That is the truth.

Question 45

The pediatric nurse understands that nonpharmacologic strategies for pain management:

a. may reduce pain perception.
b. make pharmacologic strategies unnecessary.
c. usually take too long to implement.
d. trick children into believing they do not have pain

Answer 45

ANS:A
Nonpharmacologic techniques provide coping strategies that may help reduce pain perception,
make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics.
Nonpharmacologic techniques should be learned before the pain occurs. With severe pain it is
best to use both pharmacologic and nonpharmacologic measures for pain control. The
nonpharmacologic strategy should be matched with the child’s pain severity and taught to the
child before the onset of the painful experience. Some of the techniques may facilitate the
child’s experience with mild pain, but the child will still know that discomfort is present.

Question 46

Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the
immediate postoperative period?
a. Codeine
b. Morphine
c. Methadone
d. Meperidine

Answer 46

ANS: B
The most commonly prescribed medications for PCA are morphine, hydromorphone, and
fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in
parenteral form in the United States. Meperidine is not used for continuous and extended pain
relief.

Question 47

A lumbar puncture is needed on a school-age child. The most appropriate action to provide
analgesia during this procedure is to apply:
a. 4% Liposomal Lidocaine (LMX) 15 minutes before the procedure.
b. a transdermal fentanyl (Duragesic) patch immediately before the procedure.
c. eutectic mixture of local anesthetics (EMLA) 1 hour before the procedure.
d. EMLA 30 minutes before the procedure.

Answer 47

ANS: C
EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure.
It eliminates or reduces the pain from most procedures involving skin puncture. LMX must be
applied 30 minutes before the procedure. Transdermal fentanyl patches are useful for
continuous pain control, not rapid pain control. For maximal effectiveness, EMLA must be
applied approximately 60 minutes in advance.

Question 48

The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative
pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most
appropriate management of this child is for the nurse to:
a. administer naloxone (Narcan).
b. discontinue the IV infusion.
c. discontinue morphine until the child is fully awake.
d. stimulate the child by calling his or her name, shaking gently, and asking the child to breathe deeply.

Answer 48

ANS: A
The management of opioid-induced respiratory depression includes lowering the rate of
infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be
aroused, IV naloxone should be administered. The child will be in pain because of the reversal
of the morphine. The morphine should be discontinued, but naloxone is indicated if the child
is unresponsive.

Question 49

When pain is assessed in an infant, it is inappropriate for the nurse to assess for:

a. facial expressions of pain.
b. localization of pain.
c. crying.
d. thrashing of extremities.

Answer 49

ANS: B
Infants are unable to localize pain. Frowning, grimacing, and facial flinching in an infant may
indicate pain. Infants often exhibit high-pitched, tense, harsh crying to express pain. Infants
may exhibit thrashing of extremities in response to a painful stimulus.

Question 50

The nurse caring for the child in pain understands that distraction:

a. can give total pain relief to the child.
b. is effective when the child is in severe pain.
c. is the best method for pain relief.
d. must be developmentally appropriate to refocus attention.

Answer 50

ANS: D
Distraction can be very effective in helping to control pain; however, it must be appropriate to
the child’s developmental level. Distraction can help control pain, but it is rarely able to
provide total pain relief. Children in severe pain are not distractible. Children may use
distraction to help control pain, although it is not the best method for pain relief.

Question 51

Which medication is the most effective choice for treating pain associated with sickle cell
crisis in a newly admitted 5-year-old child?
a. Morphine
b. Acetaminophen
c. Ibuprofen
d. Midazolam

Answer 51

ANS:A
Opioids, such as morphine, are the preferred drugs for the management of acute, severe pain,
including postoperative pain, posttraumatic pain, pain from vaso-occlusive crisis, and chronic
cancer pain. Acetaminophen provides only mild analgesic relief and is not appropriate for a
newly admitted child with sickle cell crisis. Ibuprofen is a type of nonsteroidal
anti-inflammatory drug (NSAID) that is used primarily for pain associated with inflammation.
It is appropriate for mild to moderate pain, but it is not adequate for this patient. Midazolam
(Versed) is a short-acting drug used for conscious sedation, for preoperative sedation, and as
an induction agent for general anesthesia.

Question 52

Which assessment indicates to a nurse that a school-aged child is in need of pain medication?

a. The child is lying rigidly in bed and not moving.
b. The child’s current vital signs are consistent with vital signs over the past 4 hours.
c. The child becomes quiet when held and cuddled.
d. The child has just returned from the recovery room.

Answer 52

ANS: A
Behaviors such as crying, distressed facial expressions, certain motor responses such as lying
rigidly in bed and not moving, and interrupted sleep patterns are indicative of pain in children.
Current vital signs that are consistent with earlier vital signs do not indicate that the child is
feeling pain. Response to comforting behaviors does not suggest that the child is feeling pain.
A child who is returning from the recovery room may or may not be in pain. Most times the
child’s pain is under adequate control at this time. The child may be fearful or having anxiety
because of the strange surroundings and having just completed surgery.

Question 53

A 2-year-old child has been returned to the nursing unit after an inguinal hernia repair. Which
pain assessment tool should the nurse use to assess this child for the presence of pain?
a. FACES pain rating tool
b. Numeric scale
c. Oucher scale
d. FLACC tool

Answer 53

ANS: D
A behavioral pain tool should be used when the child is preverbal or does not have the
language skills to express pain. The FLACC (face, legs, activity, cry, consolability) tool
should be used with a 2-year-old child. The FACES, numeric, and Oucher scales are all
self-report pain rating tools. Self-report measures are not sufficiently valid for children
younger than 3 years of age because many children are not able to self-report their pain
accurately

Question 54

A nurse is gathering a history on a school-age child admitted for a migraine headache. The
child states, “I have been getting a migraine every 2 or 3 months for the last year.” The nurse
documents this as which type of pain?
a. Acute
b. Chronic
c. Recurrent
d. Subacute

Answer 54

ANS: C
Pain that is episodic and that recurs is defined as recurrent pain. The time frame within which
episodes of pain recur is at least 3 months. Recurrent pain in children includes migraine
headache, episodic sickle cell pain, recurrent abdominal pain (RAP), and recurrent limb pain.
Acute pain is pain that lasts for less than 3 months. Chronic pain is pain that lasts, on a daily
basis, for more than 3 months. Subacute is not a term for documenting type of pain.

Question 55

An appropriate tool to assess pain in a 3-year-old child is the: (Select all that apply.)

a. Visual Analog Scale (VAS)
b. Adolescent and pediatric pain tool
c. Oucher tool
d. FACES pain-rating scale

Answer 55

ANS: C, D
The Oucher tool can be used to assess pain in children 3 to 12 years of age. The FACES
pain-rating scale can be used to assess pain for children 3 years of age and older. The VAS is
indicated for use with older school-age children and adolescents. It can be used with younger
school-age children, although less abstract tools are more appropriate. The adolescent and
pediatric pain tool is indicated for use with children 8 to 17 years of age.

Question 56

The nurse is monitoring a patient for side effects associated with opioid analgesics. Which
side effects should the nurse expect to monitor for? (Select all that apply.)
a. Diarrhea
b. Respiratory depression
c. Hypertension
d. Pruritus
e. Sweating

Answer 56

ANS: B, D, E
Side effects of opioids include respiratory depression, pruritus, and sweating. Constipation
may occur, not diarrhea, and orthostatic hypotension may occur but not hypertension.

Question 57

Which dietary recommendations should a nurse make to an adolescent patient to manage
constipation related to opioid analgesic administration? (Select all that apply.)
a. Bran cereal
b. Decrease fluid intake
c. Prune juice
d. Cheese
e. Vegetables

Answer 57

ANS: A, C, E
To manage the side effect of constipation caused by opioids, fluids should be increased, and
bran cereal and vegetables are recommended to increase fiber. Prune juice can act as a
nonpharmacologic laxative. Fluids should be increased, not decreased, and cheese can cause
constipation so it should not be recommended.

Question 58

A nurse learns that the fastest growing subset of the older population is which group?

a. Elite old
b. Middle old
c. Old old
d. Young old

Answer 58

ANS: C
The old old is the fastest growing subset of the older population. This is the group comprising
those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old
are between 75 and 84 years of age; and the elite old are over 100 years of age

Question 59

A nurse working with older adults in the community plans programming to improve morale
and emotional health in this population. What activity would best meet this goal?
a. Exercise program to improve physical function
b. Financial planning seminar series for older adults
c. Social events such as dances and group dinners
d. Workshop on prevention from becoming an abuse victim

Answer 59

ANS: A
All activities would be beneficial for the older population in the community. However, failure
in performing one’s own activities of daily living and participating in society has direct effects
on morale and life satisfaction. Those who lose the ability to function independently often feel
worthless and empty. An exercise program designed to maintain and/or improve physical
functioning would best address this need.

Question 60

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent
constipation and only wants to eat softer foods such as rice, bread, and puddings. What
assessment would the nurse perform first?
a. Auscultate bowel sounds.
b. Check skin turgor.
c. Perform an oral assessment.
d. Weigh the client.

Answer 60

ANS: C
Poorly fitting dentures and other dental problems are often manifested by a preference for soft
foods and constipation from the lack of fiber. The nurse would perform an oral assessment to
determine if these problems exist. The other assessments are important, but will not yield
information specific to the client’s food preferences as they relate to constipation.

Question 61

A nurse caring for an older adult has provided education on high-fiber foods. Which menu
selection by the client demonstrates a need for further review?
a. Barley soup
b. Black beans
c. White rice
d. Whole-wheat bread

Answer 61

ANS: C
Older adults need 35 to 50 g of fiber a day. White rice is low in fiber. Foods high in fiber
include barley, beans, and whole-wheat products.

Question 62

A nurse is working with an older client admitted with mild dehydration. What teaching does
the nurse provide to best address this issue?
a. “Cut some sodium out of your diet.”
b. “Dehydration can cause incontinence.”
c. “Have something to drink every 1 to 2 hours.”
d. “Take your diuretic in the morning.”

Answer 62

ANS: C
Older adults often lose their sense of thirst. Plus older adults have less body water than
younger people. Since they should drink 1 to 2 L of water a day, the best remedy is to have
the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting
“some” sodium from the diet will not address this issue and is vague. Although dehydration
can cause incontinence from the irritation of concentrated urine, this information will not help
prevent the problem of dehydration. Instructing the client to take a diuretic in the morning
rather than in the evening also will not directly address this issue.

Question 63

A home health care nurse is planning an exercise program with an older adult who lives at
home independently but whose mobility issues prevent much activity outside the home.
Which exercise regimen would be most beneficial to this adult?
a. Building strength and flexibility
b. Improving exercise endurance
c. Increasing aerobic capacity
d. Providing personal training

Answer 63

ANS: A
This older adult is mostly homebound. Exercise regimens for homebound clients include
things to increase functional fitness and ability for activities of daily living. Strength and
flexibility will help the client to be able to maintain independence longer. The other plans are
good but will not specifically maintain the client’s functional abilities

Question 64

An older adult recently retired and reports “being depressed and lonely.” What information
would the nurse assess as a priority?
a. History of previous depression
b. Previous stressful events
c. Role of work in the adult’s life
d. Usual leisure time activities

Answer 64

ANS: C
Establishing and maintaining relationships with others throughout life are especially important
to the older person’s happiness. When people retire, they may lose much of their social
network, leading them to feeling depressed and lonely. This loss from a sudden change in
lifestyle can easily lead to depression. The nurse would first assess the role that work played
in the client’s life. The other factors can be assessed as well, but this circumstance is
commonly seen in the older population.

Question 65

A nurse is assessing coping in older women in a support group for recent widows. Which
statement by a participant best indicates potential for successful coping?
a. “I have had the same best friend for decades.”
b. “I think I am coping very well on my own.”
c. “My kids come to see me every weekend.”
d. “Oh, I have lots of friends at the senior center

Answer 65

ANS: A
Friendship and support enhance coping. The quality of the relationship is what is most
important, however. People who have close, intimate, stable relationships with others in
whom they confide are more likely to cope with crisis. The person who is “coping well on my
own” may actually need resources to help with this transition. Having children visit is
important but not as important as intimate, long-term friendships. “Friends at the senior
center” may refer to good acquaintances and not real friends.

Question 66

A home health care nurse has conducted a home safety assessment for an older adult. There
are five concrete steps leading out from the front door. Which intervention would be most
helpful in keeping the older adult safe on the steps?
a. Have the client use a walker or cane on the steps.
b. Teach the client to hold the handrail when using the steps
c. Instruct the client to use the garage door instead.
d. Tell the client to use a two-footed gait on the steps

Answer 66

ANS:B
As a person ages, he or she may experience a decreased sense of touch. The older adult may
not be aware of where his or her foot is on the step. Combined with diminished visual acuity,
this can create a fall hazard. Holding the handrail would help keep the person safer. If the
client does not need an assistive device, he or she would not use a cane or walker just on
stairs. Using an alternative door may be necessary but does not address making the front steps
safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.

Question 67

An older adult is brought to the emergency department because of sudden onset of confusion.
After the client is stabilized and comfortable, what assessment by the nurse is most
important?
a. Assess for orthostatic hypotension.
b. Determine if there are new medications.
c. Evaluate the client for gait abnormalities.
d. Perform a delirium screening test.

Answer 67

ANS: B
Medication side effects and adverse effects are common in the older population. Something as
simple as a new antibiotic can cause confusion and memory loss. The nurse would determine
if the client is taking any new medications. Assessments for orthostatic hypotension, gait
abnormalities, and delirium may be important once more is known about the client’s
condition

Question 68

An older adult client takes medication three times a day and becomes confused about which
medication should be taken at which time. The client refuses to use a pill sorter with slots for
different times, saying “Those are for old people.” What action by the nurse would be most
helpful?
a. Arrange medications by time in a drawer.
b. Encourage the client to use easy-open tops.
c. Put color-coded stickers on the bottle caps.
d. Write a list of when to take each medication.

Answer 68

ANS: C
Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one
for evening meds, and the third color is for nighttime meds. Arranging medications by time in
a drawer might be helpful if the person doesn’t accidentally put them back in the wrong spot.
Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced.
With stickers on the medication bottles themselves, the reminder is always with the
medication

Question 69

An older adult client is in the hospital. The client is ambulatory and independent. What
intervention by the nurse would be most helpful in preventing falls in this client?
a. Keep the light on in the bathroom at night.
b. Order a bedside commode for the client.
c. Put the client on a toileting schedule.
d. Use side rails to keep the client in bed.

Answer 69

ANS: A
Although this older adult is independent and ambulatory, being hospitalized can create
confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the
light on in the bathroom will help reduce the likelihood of falling. The client does not need a
commode or a toileting schedule. Side rails used to keep the client in bed are considered
restraints and would not be used in that fashion.

Question 70

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for
pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse
calls the surgeon, which medication would he or she suggest in place of the morphine?
a. Cyclobenzaprine
b. Hydromorphone hydrochloride
c. Ketorolac
d. Meperidine

Answer 70

ANS: B
Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are
all on the Beers list of potentially inappropriate medications for use in older adults and would
not be suggested. The nurse would suggest hydromorphone hydrochloride

Question 71

A nurse admits an older adult from a home environment. The client lives with an adult son
and daughter-in-law. The client has urine burns on the skin, no dentures, and several pressure
injuries. What action by the nurse is most appropriate?
a. Ask the family how these problems occurred.
b. Call the police department and file a report.
c. Notify Adult Protective Services.
d. Report the findings as per agency policy.

Answer 71

ANS: D
These findings are suspicious for abuse. Health care providers are mandatory reporters for
suspected abuse. The nurse would notify social work, case management, or whomever is
designated in facility policies. That person can then assess the situation further. If the police
need to be notified, that is the person who will notify them. Adult Protective Services is
notified in the community setting.

Question 72

A nurse caring for an older client in the hospital is concerned the client is not competent to
give consent for upcoming surgery. What action by the nurse is best?
a. Call Adult Protective Services.
b. Discuss concerns with the health care team.
c. Do not allow the client to sign the consent.
d. Have the client’s family sign the consent.

Answer 72

ANS: B
In this situation, each facility will have a policy designed for assessing competence. The nurse
would bring these concerns to an interprofessional care team meeting. There may be
physiologic reasons for the client to be temporarily too confused or incompetent to give
consent. If an acute condition is ruled out, the staff would follow the legal procedure and
policies in their facility and state for determining competence. The key is to bring the
concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing
the consent would wait until competence is determined unless it is an emergency, in which
case the next of kin can sign if there are grave doubts as to the client’s ability to provide
consent. Simply not allowing the client to sign does not address the problem.

Question 73

A nurse working in an Acute Care of the Elderly unit learns that frailty in the older population
includes which components? (Select all that apply.)
a. Dementia
b. Exhaustion
c. Slowed physical activity
d. Weakness
e. Weight gain
f. Frequent illness

Answer 73

ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and
exhaustion, and weakness. Weight gain and dementia are not part of this syndrome. Frequent
illness could occur due to frailty, but is also not part of the syndrome

Question 74

A home health care nurse assesses an older adult for the intake of nutrients needed in larger
amounts than in younger adults. Which foods found in an older adult’s kitchen might indicate
an adequate intake of these nutrients? (Select all that apply.)
a. 1% milk
b. Carrots
c. Lean ground beef
d. Oranges
e. Vitamin D supplements
f. Cheese sticks

Answer 74

ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk and
cheese have calcium; carrots have vitamin A; vitamin D supplement has vitamin D; and
oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not
contain these needed nutrients

Question 75

A nurse working with older adults assesses them for common potential adverse medication

effects. For what does the nurse assess? (Select all that apply.)
a. Constipation
b. Dehydration
c. Mania
d. Urinary incontinence
e. Weakness
f. Anorexia

Answer 75

ANS: A, B, E, F
Common adverse medication effects include constipation/impaction, dehydration, anorexia,
and weakness. Mania and incontinence are not among the common adverse effects, although
urinary retention is.

Question 76

A nurse manager institutes the Fulmer SPICES Framework as part of the routine assessment
of older adults in the hospital. The nursing staff assesses for which factors? (Select all that
apply.)
a. Confusion
b. Evidence of abuse
c. Incontinence
d. Problems with behavior
e. Sleep disorders

Answer 76

ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion,
and evidence of falls.

Question 77

A visiting nurse is in the home of an older adult and notes a 7-lb weight loss since last
month’s visit. What actions would the nurse perform first? (Select all that apply.)
a. Assess the client’s ability to drive or transportation alternatives.
b. Determine if the client has dentures that fit appropriately.
c. Encourage the client to continue the current exercise plan.
d. Have the client complete a 3-day diet recall diary.
e. Teach the client about proper nutrition in the older population.

Answer 77

ANS: A, B, D
Assessment is the first step of the nursing process and would be completed prior to
intervening. Asking about transportation to get food, dentures, and normal food patterns
would be part of an appropriate assessment for the client. There is no information in the
question about the older adult needing to lose weight, so encouraging him or her to continue
the current exercise regimen is premature and may not be appropriate. Teaching about proper
nutrition is a good idea, but teaching needs to be tailored to the client’s needs, which the nurse
does not yet know.

Question 78

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions
does the registered nurse (RN) delegate to the assistive personnel (AP)? (Select all that apply.)
a. Assess skin redness when turning.
b. Document Braden Scale results.
c. Keep the client’s skin dry.
d. Obtain a pressure-relieving mattress.
e. Turn the client every 2 hours

Answer 78

ANS: C, D, E
The nurses’ aide or AP can assist in keeping the client’s skin dry, order a special mattress on
direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing
responsibility, although the aide would be directed to report any redness noticed.
Documenting the Braden Scale results is the RN’s responsibility as the RN is the one who
performs that assessment.

Question 79

A nurse admits an older adult to the hospital who lives at home with family. The nurse
assesses that the client is malnourished. What actions by the nurse are best? (Select all that
apply.)
a. Contact Adult Protective Services or hospital social work.
b. Request the primary health care provider prescribes tube feedings.
c. Perform and document results of a Braden Scale assessment.
d. Request a dietary consultation from the health care provider.
e. Suggest a high-protein oral supplement between meals.
f. Assess the client’s own teeth or the dentures for proper fit.

Answer 79

ANS: C, D, E, F
Malnutrition in the older population is multifactorial and has several potential adverse
outcomes. Appropriate actions by the nurse include assessing the client’s risk for skin
breakdown with the Braden Scale, requesting a consultation with a dietitian, suggesting a
high-protein meal supplement, and assessing the client’s dentures or own teeth. There is no
evidence that the client is being abused or needs a feeding tube at this time.