51. The nurse has determined the rate of both the child’s radial pulse and heart. When comparing the two rates, the nurse should expect that normally they:

a.are the same.

b.differ, with heart rate faster.

c.differ, with radial pulse faster.

d.differ, depending on quality and intensity.

52. A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?

a.Up and back

b.Down and back

c.Straight back

d.Straight up

53. The nurse has a 2-year-old boy sit in “tailor” position during palpation for the testes. What is the rationale for this position?

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.

54. 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.

55. At about what age does the Babinski sign disappear?

a.4 months

b.6 months

c.1 year

d.2 years

56. A 5-year-old girl 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.

57. Which figure depicts a nurse performing a test for the triceps reflex?

a.c.

b.d.

MULTIPLE RESPONSE

1. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. What 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.

2. Which of the following 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

3. A nurse is performing an assessment on a school-age child. Which findings suggest the child is getting an excess of vitamin A? (Select all that apply.)

a.Delayed sexual development

b.Edema

c.Pruritus

d.Jaundice

e.Paresthesia

4. 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.

ESSAY

1. Place in correct sequence, the assessment examination techniques used when performing an abdominal assessment. Begin with the first technique and end with the last. Provide answer using lowercase letters separated by commas (e.g.,  a, b, c, d).

a.   Auscultation

b.   Palpation

c.   Inspection

d.   Percussion