ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 4 : Communication and Physical Assessment of the Child and Family Questions
Question 1 of 5
Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
Correct Answer: C
Rationale: Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark-skinned individuals unless they are in the mouth or conjunctiva.
Question 2 of 5
During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
Correct Answer: C
Rationale: Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.
Question 3 of 5
The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action?
Correct Answer: B
Rationale: Hyperextension of the childs head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag.
Question 4 of 5
During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?
Correct Answer: A
Rationale: A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
Question 5 of 5
Which explains why correcting strabismus in young children is important?
Correct Answer: B
Rationale: By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes lazy, and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the corneal light reflex will not be symmetric for each eye.