Physical Assessment of Children

MULTIPLE CHOICE

1. The nurse is performing an abdominal assessment on a child. When percussing over the stomach, the nurse should hear which sound?

a.
Tympany
b.
Resonance
c.
Flatness
d.
Dullness

ANS: A

Tympany is a high-pitched, loud-intensity sound heard over air-filled body parts such as the stomach and bowel. Resonance is a low-pitched, low-intensity sound elicited over hollow organs such as the lungs. Flatness is a high-pitched, soft-intensity sound elicited by percussing over solid masses such as bone or muscle. Dullness is a medium-pitched, medium-intensity sound elicited when percussing over high-density structures such as the liver.

DIF: Cognitive Level: Application REF: p. 170

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

2. A nurse is preparing to begin an assessment on a newly admitted child. The nurse should be aware that the single most important component of a pediatric physical examination is:

a.
assessment of heart and lungs.
b.
measurement of height and weight.
c.
documentation of parental concerns.
d.
obtaining an accurate history.

ANS: D

An accurate history is most helpful in identifying problems and potential problems. Heart and lung assessment and documentation of parental concerns are not as important as an accurate history. A single measurement of height and weight is not as significant as determining growth over time. The child’s growth pattern can be elicited from the history.

DIF: Cognitive Level: Comprehension REF: p. 171

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

3. In which section of the health history should the nurse record that the parent brought the infant to the clinic today because of frequent diarrhea?

a.
Review of systems
b.
Chief complaint
c.
Lifestyle and life patterns
d.
Health history

ANS: B

The chief complaint is documented using the child’s or parent’s words for the reason the child was brought to the healthcare center. The review of systems includes past health functions of body systems. Lifestyle and life patterns include the child’s interaction with the social, psychological, physical, and cultural environment. Health history includes birth history, growth and development, common childhood illnesses, immunizations, hospitalizations, injuries, and allergies.

DIF: Cognitive Level: Comprehension REF: p. 171

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

4. A nurse is reviewing pediatric physical assessment techniques. Which statement about performing a pediatric physical assessment is correct?

a.
Physical examinations proceed systematically from head to toe unless developmental considerations dictate otherwise.
b.
The physical examination should be done with parents in the examining room for children of any age.
c.
Measurement of head circumference is done until the child is 5 years old.
d.
The physical examination is done only when the child is cooperative.

ANS: A

Physical assessment usually proceeds from head to toe; however, developmental considerations with infants and toddlers dictate that the least threatening assessments be done first to obtain accurate data. Having parents in the examining room with adolescents is not appropriate. Head circumference is routinely measured until 36 months of age. Children will not always be cooperative during the physical examination. The examiner will need to incorporate communication and play techniques to facilitate cooperation.

DIF: Cognitive Level: Comprehension REF: p. 168

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

5. A nurse is conducting an assessment on a child during a well-child visit. Which of the following includes the components of a complete pediatric history?

a.
Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns
b.
Vital signs, chief complaint, and a list of previous problems
c.
Chief complaint, including body location, quality, quantity, time frame, and alleviating and aggravating factors
d.
Pertinent developmental and family information

ANS: A

Statistical information, client profile, health history, family history, review of systems, and lifestyle and life patterns are included in a complete pediatric history. Vital signs, chief complaint, and list of previous problems do not constitute a complete history. A problem-oriented history includes specific information about the chief complaint. Pertinent developmental and family information are part of the complete history.

DIF: Cognitive Level: Comprehension REF: p. 171

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

6. At what age can the nurse expect a child’s head and chest circumference to be almost equal?

a.
Birth
b.
6 months
c.
1 year
d.
3 years

ANS: C

Head and chest measurements are almost equal at 1 year of age. Head circumference is larger than chest circumference until approximately 1 year of age. By 3 years of age, the chest circumference exceeds the head circumference.

DIF: Cognitive Level: Knowledge REF: p. 174

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

7. A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure on children. The nurse knows the UAPs have understood the teaching if they state that to obtain an accurate measurement of a child’s blood pressure, the cuff should cover which portion of the child’s upper arm?

a.
Two-thirds
b.
Three-fourths
c.
One-half
d.
One-third

ANS: A

The blood pressure cuff should cover two-thirds of the child’s upper arm to get an accurate reading. A cuff that covers more than two-thirds of the child’s upper arm will result in a false low reading. A cuff that covers less than two-thirds of the child’s upper arm will result in a false high reading.

DIF: Cognitive Level: Application REF: p. 173

OBJ: Nursing Process Step: Evaluation MSC: Safe and Effective Care Environment

8. Which chart should the nurse use to assess the visual acuity of an 8-year-old child?

a.
Lea chart
b.
Snellen chart
c.
HOTV chart
d.
Tumbling E chart

ANS: B

The Snellen chart is used to assess the vision of children older than 6 years of age. The Lea chart tests vision using four different symbols designed for use with preschool children. The HOTV chart tests vision by using graduated letters and is designed for use with children ages 3 to 6 years. The Tumbling E chart uses the letter E in various directions and is designed for use with children ages 3 to 6 years.

DIF: Cognitive Level: Comprehension REF: p. 180

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

9. Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old crying child?

a.
Ask the parent to quiet the child so the nurse can listen.
b.
Auscultate breath sounds and chart that the child was crying.
c.
Encourage the child to play with the stethoscope to distract and to calm down the child before auscultating.
d.
Document that data are not available because of noncompliance.

ANS: C

Distracting the child with an interesting activity can assist the child to calm down so an accurate assessment can be made. Asking a parent to quiet the child may or may not work. Auscultating while the child is crying typically results in less than optimal data. Documenting that the child is not compliant is not appropriate. An assessment needs to be completed.

DIF: Cognitive Level: Application REF: p. 186

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

10. Which is the most appropriate site for the nurse to use to measure a pulse rate on a 1-year-old child?

a.
Apical
b.
Radial
c.
Carotid
d.
Femoral

ANS: A

Apical pulse rates are taken in children younger than 2 years. Radial pulse rates may be taken in children older than 2 years. It is difficult to palpate the carotid pulse in an infant. The femoral pulse is palpated when comparing peripheral pulses, but it is not used to measure an infant’s pulse rate.

DIF: Cognitive Level: Comprehension REF: p. 172

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

11. What is the most appropriate action for the nurse to take when a crying toddler has a blood pressure measurement of 120/70 mm Hg?

a.
Notify the physician of the measurement.
b.
Document the blood pressure reading and check it again in 4 hours.
c.
Quiet the child and retake the blood pressure.
d.
Ask the parent if the child has a history of hypertension.

ANS: C

Blood pressure is elevated when a child is upset and crying. Quieting the child before retaking the blood pressure is appropriate. Notifying the physician is not necessary until accurate data are obtained. Documenting the blood pressure and waiting 4 hours before taking another measurement is inappropriate because this reading is not within the normal range. Asking the parent about a history of hypertension is irrelevant when a child is upset and crying as blood pressure is elevated.

DIF: Cognitive Level: Application REF: p. 173

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

12. What term should be used in the nurse’s documentation to describe auscultation of breath sounds that are short, popping, and discontinuous on inspiration?

a.
Pleural friction rub
b.
Bronchovesicular sounds
c.
Crackles
d.
Wheeze

ANS: C

Crackles are short, popping, discontinuous sounds heard on inspiration. A pleural friction rub has a grating, coarse, low-pitched sound. Bronchovesicular sounds are auscultated over mainstem bronchi. They are clear, without any adventitious sounds. Wheezes are musical, high-pitched, predominant sounds heard on expiration.

DIF: Cognitive Level: Comprehension REF: p. 188

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

13. Which strategy should be the best approach when initiating the physical examination of a 9-month-old infant?

a.
Undress the infant and do a head-to-toe examination.
b.
Have the parent hold the child on his or her lap.
c.
Put the infant on the examination table and begin assessments at the head.
d.
Ask the parent to leave because the infant will be upset.

ANS: B

Infants 6 months and older feel stranger anxiety. It is easier to do most of the examination on the parent’s lap to decrease anxiety. The head-to-toe approach needs to be modified for the infant. Uncomfortable procedures, such as the otoscopic examination, should be left until last. The infant may feel less fearful if placed in the parent’s lap or with the parent within visual range if placed on the examining table. There is no reason to ask a parent to leave when an infant is being examined. Having the parent with the infant will make the experience less upsetting for the infant.

DIF: Cognitive Level: Comprehension REF: p. 169

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

14. Which strategy is not always appropriate for a pediatric physical examination?

a.
Take the history in a quiet, private place.
b.
Examine the child from head to toe.
c.
Exhibit sensitivity to cultural needs and differences.
d.
Perform frightening procedures last.

ANS: B

The classic approach to a physical examination is to begin at the head and proceed through the entire body to the toes. When examining a child, however, the examiner must tailor the physical assessment to the child’s age and developmental level. The nurse should collect the child’s health history in a quiet, private area and painful or frightening procedures should be left to the end of the examination. The nurse should always be sensitive to cultural needs and differences among children.

DIF: Cognitive Level: Comprehension REF: p. 168

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

15. Which assessment should the nurse perform last when examining a 5-year-old child?

a.
Heart
b.
Lungs
c.
Abdomen
d.
Throat

ANS: D

Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination. The nurse may proceed from head to toe with preschool age children. Assessment of the abdomen and lungs is not considered to be frightening.

DIF: Cognitive Level: Application REF: p. 169

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

16. When would be the most appropriate time to inspect the genital area during a well-child examination of a 14-year-old female?

a.
It is not necessary to inspect the genital area.
b.
Examine the genital area first.
c.
After the abdominal assessment.
d.
Do the genital inspection last.

ANS: C

It is best to incorporate the genital assessment into the middle of the examination. This allows ample time for questions and discussion. If possible, proceed from the abdominal area to the genital area. A visual inspection of all areas of the body is included in a physical examination. Examination of the genital area can be embarrassing. It would not be appropriate to begin the examination of this area. Assessing the genital area earlier in the examination allows more time for the adolescent to ask questions and engage in discussion.

DIF: Cognitive Level: Application REF: p. 169

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

17. Which measurement is not indicated for a 4-year-old well-child examination?

a.
Blood pressure
b.
Weight
c.
Height
d.
Head circumference

ANS: D

Head circumference is measured on all children from birth to 3 years. Blood pressure measurements are taken on all children at every ambulatory visit. Weight and height are measured at every well-child examination.

DIF: Cognitive Level: Comprehension REF: p. 174

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

18. The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or violet color. This skin coloration is associated with which?

a.
Cyanosis
b.
Erythema
c.
Vitiligo
d.
Nevi

ANS: B

In dark-skinned children, erythema appears as dusky red or violet skin coloration. Cyanosis in a dark-skinned child would appear as a black coloration of the skin. Vitiligo refers to areas of depigmentation. Nevi are areas of increased pigmentation.

DIF: Cognitive Level: Comprehension REF: p. 175

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

19. The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed. What would this finding indicate?

a.
This is a normal finding.
b.
This finding indicates premature closure of cranial sutures.
c.
This is an abnormal finding and the child should have a developmental evaluation.
d.
This is an abnormal finding and the child should have a neurological evaluation.

ANS: A

The anterior fontanel should be completely closed by 12 to 18 months of age. A closed anterior fontanel at 14 months of age does not indicate premature closure of cranial sutures, is not abnormal, and does not indicate the need for a neurological examination.

DIF: Cognitive Level: Analysis REF: p. 177

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

20. A nurse is conducting vision screening on preschool children. Which of the following corresponds with the normal range for visual acuity of a 4-year-old child?

a.
20/50 to 20/80
b.
20/40 to 20/70
c.
20/30 to 20/40
d.
20/20 to 20/30

ANS: C

20/30 to 20/40 is the normal range for visual acuity at 4 years of age. 20/50 to 20/80 is the normal range for visual acuity at 4 months of age. 20/40 to 20/70 is the normal range for visual acuity at 1 year of age. 20/20 to 20/30 is the normal range for visual acuity at 5 years of age.

DIF: Cognitive Level: Application REF: p. 180

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

21. A child begins to squirm and giggle when the nurse begins to palpate the abdomen. What is the best approach for the nurse to use with a child who is ticklish?

a.
Skip the abdominal palpation.
b.
Touch the abdomen firmly as the child takes short, quick breaths.
c.
Press the abdomen with the child bearing down and holding the breath.
d.
Palpate with the child’s hand under the examiner’s hand.

ANS: D

Placing the child’s hand on the abdomen and the examiner’s hand on top of the child’s hand with fingers touching the abdomen gives the child some control and reduces the sensation of tickling. Abdominal palpation should not be eliminated from the physical assessment. To help the child relax, the nurse would ask the child to take deep breaths. Bearing down and holding the breath would tighten the abdominal muscles.

DIF: Cognitive Level: Application REF: p. 191

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

22. Which cranial nerve is assessed when the child is asked to imitate the examiner’s wrinkled frown, wrinkled forehead, smile, and raised eyebrow?

a.
Accessory
b.
Hypoglossal
c.
Trigeminal
d.
Facial

ANS: D

The facial nerve is assessed as described in the question. To assess the accessory nerve, the examiner palpates and notes the strength of the trapezius and sternocleidomastoid muscles against resistance. To assess the hypoglossal nerve, the examiner asks the child to stick out the tongue. To assess the trigeminal nerve, the child is asked to identify a wisp of cotton on the face. The corneal reflex and temporal and masseter muscle strength are evaluated.

DIF: Cognitive Level: Comprehension REF: p. 196

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

23. Which assessment finding is considered a neurological soft sign in a 7-year-old child?

a.
Plantar reflex
b.
Poor muscle coordination
c.
Stereognostic function
d.
Graphesthesia

ANS: B

Poor muscle coordination is a neurological soft sign. The plantar reflex is a normal response. When the lateral aspect of the sole of the foot is stroked in a movement curving medially from the heel to the ball, the response will be plantar flexion of the toes. Stereognostic function refers to the ability to identify familiar objects placed in each hand. Graphesthesia is the ability to identify letters or numbers traced on the palm or back of the hand with a blunt point.

DIF: Cognitive Level: Comprehension REF: p. 198

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. A nurse is performing an assessment on a newborn. Which vital signs indicate a normal finding for this age group? Select all that apply.

a.
Pulse of 80 to 125 a minute
b.
B/P of systolic 65 to 95 and diastolic 30 to 60
c.
Temperature of 36.5° to 37.3° Celsius (axillary)
d.
Temperature of 36.4° to 37° Celsius (axillary)
e.
Respirations of 30 to 60 a minute

ANS: B, C, E

The normal vital signs for a newborn are temperature 36.5° to 37.3° Celsius (axillary), pulse rate of 120 to 160 a minute, respiratory rate of 30 to 60 a minute, systolic B/P of 65 to 95, and diastolic B/P of 30 to 62. A temperature of 36.4° to 37° Celsius is normal for an older child. A pulse rate of 80 to 125 is normal for a 4-year-old child.

DIF: Cognitive Level: Application REF: p. 172

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

2. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? Select all that apply.

a.
Pain with deep palpation of the spinal column
b.
Unequal shoulder heights
c.
The trouser pant leg length appears shorter on one side
d.
Inability to bend at the waist
e.
Unequal waist angles

ANS: B, C, E

The assessment findings associated with scoliosis include unequal shoulder heights, trouser pant leg length appearing shorter on one side meaning unequal leg length, and unequal waist angles. Scoliosis is a nonpainful curvature of the spine so pain is not expected and the child is able to bend at the waist adequately.

DIF: Cognitive Level: Application REF: p. 195

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance