PTS:1DIF:Cognitive Level: Knowledge/RememberingREF:p. 725OBJ:Nursing Process: AssessmentMSC:Client Needs: Health Promotion and Maintenance18.The nurse palpated the anterior fontanel of a 14-month-old infant and found that itwas closed. What does this finding indicate?a.This is a normal finding.b.This finding indicates premature closure of cranial sutures.c.This is abnormal, and the child should have a developmental evaluation.d.This is an abnormal finding, and the child should have a neurologic evaluation.ANS:AThe anterior fontanel should be completely closed by 12 to 18 months of age. It does notmean premature closure or indicate a need for developmental or neurologic evaluations.PTS:1DIF:Cognitive Level: Knowledge/RememberingREF:p. 727OBJ:Nursing Process: AssessmentMSC:Client Needs: Health Promotion and Maintenance19.The nurse is assessing a 4-year-old child’s visual acuity. The results indicate a visual acuityof 20/40 in both eyes. The child’s father asks the nurse about his son’s results. Whichresponse, if made by the nurse, is correct?a.“Your child will need a referral to the ophthalmologist before he can attendpreschool next week.”b.“Your child’s visual acuity is normal for his age.”c.“The results of this test indicate your child may be color blind.”d.“Your child did not pass; he will need to see an eye doctor.”ANS:BNormal visual acuity for a 4-year-old is 20/40 to 20/50. This finding is normal. No otheraction is needed.PTS:1DIF:Cognitive Level: Application/ApplyingREF:p. 732OBJ:Nursing Process: AssessmentMSC:Client Needs: Health Promotion and Maintenance20.When interviewing the mother of a 3-year-old child, the nurse asks aboutdevelopmental milestones. This should be considereda.unnecessary information, because the child is 3 years old.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.ANS:C
Information about the attainment of developmental milestones is necessary and importantto obtain. It provides data about the child’s growth and development that should beincluded in the history. Developmental milestones provide important information about thechild’s physical, social, and neurologic health. The developmental milestones are specific tothis child. If pertinent, attainment of milestones by siblings should be included in the familyhistory. The review of systems does not include the developmental milestones.PTS:1DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 721OBJ:Nursing Process: AssessmentMSC:Client Needs: Health Promotion and Maintenance21.Which cranial nerve is assessed when the child is asked to imitate the examiner’s wrinkledfrown, wrinkled forehead, smile, and raised eyebrow?a.Accessoryb.Hypoglossalc.Trigeminald.FacialANS:DThe facial nerve is assessed as described in the question. To assess the accessory nerve, theexaminer palpates and notes the strength of the trapezius and sternocleidomastoid musclesagainst resistance. To assess the hypoglossal nerve, the examiner asks the child to stick outthe tongue. To assess the trigeminal nerve, the child is asked to identify a wisp of cotton onthe face. The corneal reflex and temporal and masseter muscle strength are evaluated.
Upload your study docs or become a
Course Hero member to access this document
Upload your study docs or become a
Course Hero member to access this document
End of preview. Want to read all 609 pages?
Upload your study docs or become a
Course Hero member to access this document
Term
Fall
Professor
N/A
Tags
