Communication and Physical Assessment of the Child

1. The nurse is seeing an adolescent boy and his parents in the clinic for the first time. Which of the following should the nurse do first?
a. Introduce self.
b. Make family comfortable.

c. Explain purpose of interview. d. Give assurance of privacy.

ANS: A
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.
b. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease.
c. Clarification of the purpose of the interview and the nurse’s role is the next thing that should be done.
d. 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.

DIF: Cognitive Level: Application REF: Page 98
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

2. Which of the following 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.

ANS: C
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.
a. 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.

Test Bank 6-2

b. Direct questions may obtain limited information. In addition, the parent may consider them threatening.
d. 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.

DIF: Cognitive Level: Application REF: Page 100
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

3. Which of the following is considered a block to effective communication? a. Using silence
b. Using clichés
c. Directing the focus

d. Defining the problem

ANS: B
b. Using stereotyped comments or clichés can block effective communication. After use of such trite phrases, parents will often not respond.
a. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.
c. To be effective, the nurse must be able to direct the focus of the interview while allowing maximal freedom of expression. By using open-ended questions, along with guiding questions, the nurse can obtain the necessary information and maintain the relationship with the family.
d. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention.

DIF: Cognitive Level: Application REF: Page 102
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

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

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

ANS: C
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.
a. Although the child’s physical condition is a consideration, developmental level is much more important.
b. The parents’ presence is important when communicating with young children, but may be detrimental when speaking with adolescents.

Test Bank 6-3

d. Nonverbal behaviors will vary in importance based on the child’s developmental level.

DIF: Cognitive Level: Comprehension REF: Page 102
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

5. Which of the following approaches would be best to use to ensure a positive response from a toddler?
a. Assume an eye-level position and talk quietly.
b. Call the toddler’s name while picking him or her up.

c. Call the toddler’s name and say, “I’m your nurse.” d. Stand by the toddler, addressing him or her by name.

ANS: A
a. It is important that the nurse assume a position at the child’s level when communicating with the child. By speaking quietly and focusing on the child, the nurse should be able to obtain a positive response.
b. The nurse should engage the child and inform the toddler what is going to occur. If the nurse picks up the child without explanation, the child is most likely going to become upset.
c. The toddler may not understand the meaning of the phrase, “I’m your nurse.”
d. If a positive response is desired, the nurse should assume the child’s level when speaking if possible.

DIF: Cognitive Level: Application REF: Page 103
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

6. Which of the following 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 child when parent is not present.

ANS: B
b. Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This will facilitate communication with this age child. a. Speaking in this manner will tend to increase anxiety in very young children.
c. The nurse must be honest with the child. Attempts at deception will lead to a lack of trust.
d. Whenever possible, the parent should be present for interactions with young children.

DIF: Cognitive Level: Comprehension REF: Page 103 TOP: Integrated Process: Communication and Documentation

Test Bank 6-4

MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

7. Because children younger than 5 years are egocentric, the nurse should do which of the following when communicating with young children?
a. Focus communication on child.
b. Explain experiences of others to child.

c. Use easy analogies when possible.
d. Assure child that communication is private.

ANS: A
a. Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel.
b, c, and d. With children who are egocentric, these approaches will not be effective because the child is not capable of understanding.

DIF: Cognitive Level: Comprehension REF: Page 104
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

8. The nurse’s approach, when introducing hospital equipment to a preschooler who seems afraid, should be based on which of the following principles?
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 child’s fear.
d. One brief explanation will be enough to reduce the child’s fear.

ANS: A
a. Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed.
b. The child should be given simple concrete explanations about what the equipment does and how it will feel to the child.
c. Simple, concrete explanations will help alleviate the child’s fear.
d. The preschooler will need repeated explanations as reassurance.

DIF: Cognitive Level: Analysis REF: Page 104
TOP: Integrated Process: Nursing Process: Implementation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

9. Which age-group is most concerned with body integrity? a. Toddler

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

ANS: C
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 6-5

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.
a, b, and d. Body integrity is not as important a concern to children in these age- groups.

DIF: Cognitive Level: Comprehension REF: Page 104
TOP: Integrated Process: Nursing Process: Planning
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development

10. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which of the following?
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
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. A nurse should respond positively for requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child.
b. The child is not exhibiting anxiety, just requesting clarification of what will be occurring.
d. The nurse must explain how the blood pressure cuff works so that the child can then observe during the procedure.

DIF: Cognitive Level: Comprehension REF:
TOP: Integrated Process: Teaching/Learning
MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development

11. When the nurse interviews an adolescent, which of the following is especially important?

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 adolescent.

ANS: B
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.

Page 104

Test Bank 6-6

a. Although the peer group is important to this age-group, the focus of the interview should be on the adolescent.
c. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality.

d. 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.

DIF: Cognitive Level: Comprehension REF: Page 104
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

12. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might 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 if the child is always uncommunicative. d. Ask the child to draw a picture.

ANS: D
d. Drawing is one of the most valuable forms of communication. Children’s drawings tell a great deal about them because they are projections of the child’s inner self.
a. This would be difficult for a 6-year-old child, who is most likely learning to read. b. This is a passive activity involving the parent and child. It would not facilitate communication with the nurse.
c. The child is in a stressful situation and is probably uncomfortable with strangers.

DIF: Cognitive Level: Application REF: Page 107
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

13. 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 which of the following?
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

ANS: B
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. a. Magic tricks appeal to the natural curiosity of young children.
c and d. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic.

Test Bank 6-7

DIF: Cognitive Level: Analysis REF: Page 107
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

14. The nurse must assess 10-month-old Chad. He is sitting on his father’s lap and appears to be afraid of the nurse and of what might happen next. Which of the following initial actions by the nurse would be most appropriate?
a. Initiate a game of peek-a-boo.

b. Ask father to place Chad on the examination table.
c. Undress Chad while he is still sitting on his father’s lap. d. Talk softly to Chad while taking him from his father.

ANS: A
a. Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance.
b and d. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done on the father’s lap.
c. The nurse should have the father undress the child as needed for the examination.

DIF: Cognitive Level: Application REF: Page 105
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:PsychosocialIntegrity:TherapeuticCommunication

15. The nurse is taking a health history on an adolescent. Which of the following best describes how the chief complaint should be determined?
a. Ask for detailed listing of symptoms.
b. Ask adolescent, “Why did you come here today?”

c. Use what adolescent says to determine, in correct medical terminology, what the problem is.

d. Interview parent away from adolescent to determine chief complaint.

ANS: B
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. This will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him to seek help at this time.
c. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help.
d. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time.

DIF: Cognitive Level: Application REF: Page 107
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

Test Bank 6-8

16. 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

ANS: C
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.
a. Past history refers to information that relates to previous aspects of the child’s health, not to the current problem.
b. 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.
d. The review of systems is a specific review of each body system.

DIF: Cognitive Level: Comprehension REF: Page 108
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

17. 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 of the following headings?
a. Past history

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

ANS: A
a. The past 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.
b. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless chief complaint is directly related to the prematurity, this information is not included in the history of present illness.
c. 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.
d. 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.

DIF: Cognitive Level: Comprehension REF: Page 109
Mosby items and derived items © 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

Test Bank 6-9

TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

18. Where in the health history does a record of immunizations belong? a. Past history

b. Present illness
c. Review of systems d. Physical assessment

ANS: A
a. The past history contains information relating to all previous aspects of the child’s health status. The immunizations are appropriately included in the past history.
b, c, and d. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status.

DIF: Cognitive Level: Comprehension REF: Page 109
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

19. 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:
a. unnecessary information because child is age 3 years.
b. an important part of the family history.
c. an important part of the child’s past history.
d. an important part of the child’s review of systems.

ANS: C
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 past history.
a. Developmental milestones provide important information about the child’s physical, social, and neurologic health.
b. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings would be included in the family history.
d. The review of systems does not include the developmental milestones.

DIF: Cognitive Level: Comprehension REF: Page 109
TOP: Integrated Process: Communication and Documentation
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Developmental Stages and Transitions

20. The nurse is taking a sexual history on an adolescent girl. Which of the following is the best way to determine whether she is sexually active?
a. Ask her, “Are you sexually active?”

Test Bank 6-10

Ask her, “Are you having sex with anyone?”
Ask her, “Are you having sex with a boyfriend?”
Ask both the girl and her parent if she is sexually active.

ANS: B
b. Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood.
a. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care.
c. 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.
d. Questioning about sexual activity should occur when the adolescent is alone.

DIF: Cognitive Level: Application REF: Page 110 | Page 111 TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

21. When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet:
a. indicates 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
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. a. Many cultures use diets that contain this combination of foods. It is not indicative of poverty.
b. Combinations of foods contain the essential amino acids necessary for growth.
d. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.

DIF: Cognitive Level: Application REF: Page 114
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

22. Which of the following parameters correlates best with measurements of the body’s total protein stores?

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

Test Bank 6-11

ANS: D
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.
a. Height is reflective of past nutritional status.
b. Weight is indicative of current nutritional status.
c. Skin-fold thickness is a measurement of the body’s fat content.

DIF: Cognitive Level: Comprehension REF: Page 115
TOP: Integrated Process: Nursing Process: Assessment
MSC: AreaofClientNeeds:HealthPromotionandMaintenance:Healthand Wellness

23. Which of the following is an appropriate approach to performing a physical assessment on a toddler?
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
c. Parents can remove 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. a. The head-to-toe assessment can be done in older children but usually must be adapted in younger children.
b. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation.
d. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age-group.

DIF: Cognitive Level: Comprehension REF: Page 118
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

24. The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. This action should be considered which of the following?
a. Appropriate because of child’s age

b. Appropriate because mother would be uncomfortable making decisions for child c. Inappropriate because of child’s age
d. Inappropriate because child is same sex as mother

ANS: A
a. The older school-age child should be given the option of having the parent present or not. During the examination, the nurse should respect the child’s need for privacy.

Test Bank 6-12

b. Although the question was appropriate for the child’s age, the mother is responsible for making decisions for the child.
c. It is appropriate because of the child’s age.
d. During the examination, the nurse must respect the child’s privacy. The child should help determine who is present during the examination.

DIF: Cognitive Level: Comprehension REF: Page 120
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

25. With the National Center for Health Statistics (NCHS) criteria, which one of the following body mass index (BMI)–for-age percentiles indicates a risk for being overweight?
a. 10th percentile

b. 9th percentile c. 85th percentile d. 95th percentile

ANS: C
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.
a and b. These children are within normal limits.
d. Children who are greater than or equal to the 95th percentile are considered overweight.

DIF: Cognitive Level: Comprehension REF: Page 122
TOP: Integrated Process: Nursing Process: Problem Identification
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

26. The nurse is using the NCHS growth chart for an African-American child. Which of the following should the nurse consider?
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
d. The NCHS growth charts can serve as reference guides for all racial or ethnic groups. U.S. African American-children were included in the sample population. a and b. The growth chart can be used with the perspective that different groups of children have varying normal distributions on the growth curves.
c. No correction factor exists.

Test Bank 6-13

DIF: Cognitive Level: Comprehension REF: Page 122
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

27. Which one of the following tools measures body fat most accurately? a. Stadiometer

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

ANS: B
b. Calipers are used to measure skin-fold thickness, which is an indicator of body fat content.
a. Stadiometers are used to measure height.
c. Cloth tape measures should not be used because they can stretch.
d. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.

DIF: Cognitive Level: Comprehension REF: Page 124
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

28. The nurse is using calipers to measure skin-fold thickness over the triceps muscle in a school-age child. What is the purpose of doing this?
a. To measure body fat
b. To measure muscle mass

c. To determine arm circumference
d. To determine accuracy of weight measurement

ANS: A
a. Measurement of skin-fold thickness is an indicator of body fat.
b and c. Arm circumference is an indirect measure of muscle mass.
d. The accuracy of weight measurement should be verified with a properly balanced scale. Body fat is just one indicator of weight.

DIF: Cognitive Level: Knowledge REF: Page 124
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

29. 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 1/2 to 3 years

Test Bank 6-14

ANS: C
c. Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal.
a and b. Head circumference is larger than chest circumference at these ages.
d. Chest circumference is larger than head circumference at this age.

DIF: Cognitive Level: Comprehension REF: Page 124
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

30. Which of the following would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?
a. Axillary sensor
b. Tympanic membrane sensor

c. Rectal mercury glass thermometer d. Rectal electronic thermometer

ANS: A
a. The axillary sensor measures the infrared heat energy radiating from the axilla. It can be used on wet skin, in incubators, or under radiant warmers.
b. Ear thermometry does not show sufficient correlation with established methods of measurement. It should not be used when body temperature must be assessed with precision.
c. Mercury thermometers should never be used. The release of mercury, should the thermometer be broken, can cause harmful vapors.
d. Rectal temperatures should be avoided unless no other suitable way exists for the temperature to be measured.

DIF: Cognitive Level: Application REF: Page 127
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

31. What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year

b. 2 years c. 3 years d. 6 years

ANS: B
b. Satisfactory radial pulses can be used in children older than 2 years. a. In infants and young children, the apical pulse is more reliable.
c and d. The apical pulse can be used for assessment at these ages.

DIF: Cognitive Level: Comprehension REF: Page 127 TOP: Integrated Process: Nursing Process: Assessment

Test Bank 6-15

MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

32. Pulses can be graded according to certain criteria. Which of the following is a description of a normal pulse?
a. 0
b. +1

c. +2 d. +3

ANS: D
d. A normal pulse is described as +3. A pulse that is easy to palpate and not easily obliterated with pressure is considered normal.
a. A pulse graded 0 is not palpable.
b. A pulse graded +1 is difficult to palpate, thready, weak, and easily obliterated with pressure.
c. A pulse graded +2 is difficult to palpate and may be easily obliterated with pressure.

DIF: Cognitive Level: Comprehension REF: Page 129
TOP: Integrated Process: Nursing Process: Assessment
MSC: Area of Client Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

33. 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