Chapter 09: Physical Assessment of Children Test Bank: Multiple Choice

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Chapter 09: Physical Assessment of Children

Test Bank
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 childs growth pattern can be elicited from the history.
DIF: Cognitive Level: Comprehension REF: p. 171
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 childs or parents 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 childs 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.
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?
Physical examinations proceed systematically from head to toe unless developmental considerations
a. 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.
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?
Statistical information, client profile, health history, family history, review of systems, and lifestyle a
a. 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 aggravat
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.
6. At what age can the nurse expect a childs 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
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 childs blood pressure, the cuff should cover which portion of the
childs 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 childs upper arm to get an accurate
reading. A cuff that covers more than two-thirds of the childs upper arm will result in a false low
reading. A cuff that covers less than two-thirds of the childs upper arm will result in a false high
reading.
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.
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 auscul
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.
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 infants pulse
rate.
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.
12. What term should be used in the nurses 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.
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
parents 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 parents 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.
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 childs age and developmental level. The nurse should collect the childs 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.
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.
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.
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.
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.
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
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.
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 childs hand under the examiners hand.
ANS: D
Placing the childs hand on the abdomen and the examiners hand on top of the childs 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.
22. Which cranial nerve is assessed when the child is asked to imitate the examiners 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.
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.
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.
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.
OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

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Chapter 09: Physical Assessment of Children

development, common childhood illnesses, immunizations, hospitalizations, injuries, and

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