Chapter 29: The Complete Physical Assessment: Infant, Young Child, and Adolescent Jarvis: Physical Examination and Health Assessment, 8th Edition

Multiple Choice

1. A 5-year-old child is in the clinic for a checkup. When performing the physical examination, what would the nurse expect?

a. Needs to be held on his mother’s lap.

b. Is able to sit on the examination table.

c. Is able to stand on the floor for the examination.

d. Is able to remain alone in the examination room.

ANS: B

At 4 or 5 years old, a child usually feels comfortable on the examination table. Older infants and young children aged 6 months to 2 or 3 years should be positioned in the parent’s lap.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Eliciting the Moro reflex b. Performing the Romberg test c. Assessing the stepping reflex d. Checking for the Ortolani sign

2. When assessing the neonate, the nurse should test for hip stability with which method?

ANS: D

The nurse should test for hip stability in the neonate by testing for the Ortolani sign. The other tests are not appropriate for testing hip stability.

DIF: Cognitive Level: Understanding (Comprehension)

MSC: Client Needs: Health Promotion and Maintenance a. Testing for Ortolani sign b. Blood pressure measurement c. Assessment for stereognosis d. Assessment for the presence of the startle reflex

3. Which of these actions is most appropriate to perform on a 9-month-old infant at a well-child checkup?

ANS: A

Until the age of 12 months, the infant should be assessed for Ortolani sign. If Ortolani sign is present, then it could indicate the presence of a dislocated hip. The other tests are not appropriate for a 9-month-old child.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Defer assessment of the inguinal area for hernias. b. Have the patient remain in his street clothes and work around them. c. Allow the patient’s mother to remain in the room during the examination. d. Allow the patient to remain in the sitting position for examination of the abdomen.

4. A fourteen-year-old male is being seen at the clinic for a well-person exam. How should the nurse proceed?

ANS: B

The major task of adolescence is to develop a self-identity. The adolescent is increasingly self-conscious and introspective. For a well-person exam, keep the adolescent in street clothes and work around them. Assessment of the inguinal area should not be deferred, instead, ask the patient to unzip and lower their jeans or pants under a drape. The patient’s mother should be asked to leave the room so that the patient can talk freely. The patient should assume a supine position for the abdominal examination.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance a. Blood pressure b. Babinski reflex c. Palpate the testes d. Elicit the Moro reflex

5. The nurse is conducting a complete physical assessment of a 6-month-old infant. Which assessment should the nurse perform last?

ANS: D

The final procedures in a complete physical assessment of an infant are the otoscope exam of the auditory canals and tympanic membranes and the Moro reflex. These are done last as they often cause the infant to cry and may be difficult to calm. Blood pressure is not usually assessed for infants. The Babinski reflex can be performed when assessing the lower extremities and palpation of the testes can be performed when assessing genitalia.

DIF: Cognitive Level: Applying (Application)

MSC: Client Needs: Health Promotion and Maintenance