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What is the earliest age at which a satisfactory radial pulse can be taken in children?
- A. 1 year
- B. 2 years
- C. 3 years
- D. 6 years
Correct Answer: B
Rationale: Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.
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The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?
- A. Ask her, Are you sexually active?
- B. Ask her, Are you having sex with anyone?
- C. Ask her, Are you having sex with a boyfriend?
- D. Ask both the girl and her parent if she is sexually active.
Correct Answer: B
Rationale: Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Using gender-neutral terms is inclusive and conveys acceptance to the adolescent. Questioning about sexual activity should occur when the adolescent is alone.
Which is the most frequently used test for measuring visual acuity?
- A. Snellen letter chart
- B. Ishihara vision test
- C. Allen picture card test
- D. Denver eye screening test
Correct Answer: A
Rationale: The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. The Ishihara Vision Test is used for color vision. The Allen picture card test and Denver eye screening test involve single cards for children ages 2 years and older who are unable to use the Snellen letter chart.
The nurse is interviewing the mother of an infant. The mother reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading?
- A. History
- B. Present illness
- C. Chief complaint
- D. Review of systems
Correct Answer: A
Rationale: The history refers to information that relates to previous aspects of the childs health, not to the current problem. The difficult delivery and prematurity are important parts of the infants history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.
Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
- A. Face
- B. Buttocks
- C. Oral mucosa
- D. Palms and soles
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.
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?
- A. Appropriate because of childs age
- B. Appropriate, but the mother may be uncomfortable
- C. Inappropriate because of childs age
- D. Inappropriate because child is same sex as mother
Correct Answer: A
Rationale: It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination.