The umbo upward to the margin of the membrane the

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the umbo upward to the margin of the membrane. The tympanic membrane should be light pearly pink or gray and translucent, not nontransparent. Ashen gray areas indicate signs of scarring from a previous perforation. DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 2. The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) a. Wheezes b. Crackles c. Vesicular d. Bronchial e. Bronchovesicular ANS: C, D, E Normal breath sounds are classified as vesicular, bronchovesicular, or bronchial. Wheezes or crackles are abnormal or adventitious sounds. DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 3. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) a. Lightly brush the palate with a cotton swab. b. Perform the examination in front of a mirror. c. Let the child examine someone elses mouth first. d. Have the child breathe deeply and hold his or her breath. e. Use a tongue blade to help the child open his or her mouth. ANS: A, B, C, D To encourage a child to open the mouth for examination, the nurse can lightly brush the palate with a cotton swab, perform the examination in front of a mirror, let the child examine someone elses mouth first, and have Test Bank - Wong's Nursing Care of Infants and Children (11e by Hockenberry) 73
the child breathe deeply and hold his or her breath. A tongue blade may elicit the gag reflex and should not be used. DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity 4. Which are effective auscultation techniques? (Select all that apply.) a. Ask the child to breathe shallowly. b. Apply light pressure on the chest piece. c. Use a symmetric and orderly approach. d. Place the stethoscope over one layer of clothing. e. Warm the stethoscope before placing it on the skin. ANS: C, E Effective auscultation techniques include using a symmetric approach and warming the stethoscope before placing it on the skin. Breath sounds are best heard if the child inspires deeply, not shallowly. Firm, not light, pressure should be used on the chest piece. The stethoscope should be placed on the skin, not over clothing. DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

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