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Test Bank Answers Infants, Children, and Adolescents Ch.26

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 26 Infants, Children, and Adolescents

The nurse is preparing to discuss growth and development with expectant parents. Which growth patterns should the nurse consider prior to discussing the information? Select all that apply.

1. Cephalocaudal direction.

2. Simple to complex.

3. Distal to proximal direction.

4. Generalized response to specific response.

5. Anterior to posterior.

Page Ref: 688

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

When reviewing a pediatric client's medical record, which should the nurse consider environmental factors that influence growth and development? Select all that apply.

1. Nutrition.

2. Climate.

3. Heredity.

4. Culture.

5. Religion.

Page Ref: 688

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

Which parental statement reflects appropriate behavior for Piaget's sensorimotor stage of development?

1. "We have started buying more colorful toys."

2. "We play with water toys in the bathtub."

3. "We bought some blocks with numbers."

4. "We have been playing peek-a-boo."

Page Ref: 690

Cognitive Level: Analyzing

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

Which goal reflects a child's accomplishment of the task for Erikson's Stage 4 of development?

1. Watch peers play team sports.

2. Identify one or two pets that would be fun to care for.

3. Complete school homework and have a passing grade within 1 month.

4. Volunteer to help with one or more community projects each week.

Page Ref: 690

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

A parent asks the nurse when their child will have 20/20 vision. Which time frame should the nurse respond to the client with?

1. 1 yr.

2. 3 yrs.

3. 5 yrs.

4. 7 yrs.

Page Ref: 678

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

The nurse is interviewing the mother of a toddler who verbalizes concerns that her child uses the toilet to void but refuses to use the toilet for bowel movements and often hides to defecate. Which stage of Freud's psychologic development is this toddler experiencing?

1. Genital.

2. Phallic.

3. Anal.

4. Latency.

Page Ref: 690

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

According to Piaget's theory of cognitive development, which behaviors should the nurse expect when assessing a preschool-age client? Select all that apply.

1. Being egocentric and failing to see another's point of view.

2. Focusing on one aspect of a given situation at once.

3. Assuming everyone else in their world sees things as they do.

4. Believing in magical powers of thought to control the universe.

5. Understanding cause-and-effect relationships.

Page Ref: 690

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

While assessing a preschool-age child at play, which behavior indicates that the child is successfully moving through Piaget's cognitive stages of development?

1. The child is able to consider the differing opinions of playmates.

2. The child is able to recall the good time experienced in the previous weekend at the playground and is anticipating going there again the following week.

3. The child reports being able to rationalize why it is better to eat fruit than candy.

4. The child understands that their mother loves them as much as they love the child's older siblings.

Page Ref: 690

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

A client asks the nurse what the pink patches are on the back of the neck of their newborn. Which newborn finding should the nurse be prepared to discuss?

1. Vernix caseosa.

2. Lanugo.

3. Nevus flammeus.

4. Transient mottling.

Page Ref: 677

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

A parent asks the nurse when their baby's anterior fontanel will close. Which information should the nurse provide the parent?

1. 4 weeks to 3 months.

2. 3 to 6 months.

3. 9 to 12 months.

4. 12 to 18 months.

Page Ref: 678

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to collect data from a parent of a toddler suspected to have a middle ear infection. Which symptoms should the nurse associate with the infection? Select all that apply.

1. Fever.

2. Diarrhea

3. Irritability.

4. Decreased appetite.

5. Inability to sleep laying down.

Page Ref: 679

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse notes that a 3-year-old client has yellow-green nasal discharge. Which type of infection should the nurse suspect?

1. Ear.

2. Frontal Sinus.

3. Throat.

4. Upper respiratory.

Page Ref: 679

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

An adolescent male expresses concern to the nurse about their enlarged breast tissue. Which response should the nurse provide the client?

1. "This change will resolve on its own."

2. "This may be due to a hormone imbalance."

3. "Are you experiencing any breast pain?"

4. "Have you noticed any lumps in the tissue?"

Page Ref: 681

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.2. Plan questions related to infants, children, and adolescents for the focused interview.

The nurse is preparing to assess the blood pressure of a young child. Which technique should the nurse use to assess the pressure?

1. Left arm.

2. Both arms.

3. Arm and thigh.

4. Right arm.

Page Ref: 682

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 26.4: Outline the techniques for physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.3. Utilize the appropriate techniques and tools for physical assessment of infants, children, and adolescents.

The nurse is assessing a child urine output. The child weighs 64 lbs. Which should the nurse identify as the minimal acceptable output? ________ ml/hr.

Page Ref: 684

Cognitive Level: Applying

Client Need & Sub: Physiological Integrity; Elimination

Learning Outcome: 26.4: Outline the techniques for physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to assess a child with exacerbated asthma. Which initial symptoms should the nurse anticipate? Select all that apply.

1. Nasal flaring.

2. Cyanosis.

3. Failure to thrive.

4. Increased respiratory rate.

5. Accessory muscle use.

Page Ref: 700

Cognitive Level: Understanding

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is caring for a newborn with a congenital heart disorder. Which should the nurse monitor the client for?

1. Hypothermia.

2. Hypoglycemia.

3. Poor feeding.

4. Fussiness.

Page Ref: 700

Cognitive Level: Analyzing

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The parent of a 2-day-old newborn expresses concern that their infant's head is misshapen. Which response should the nurse provide the parent?

1. "Every newborn has a different shaped head."

2. "It is okay, the cranial bones are not yet fused."

3. "I will be taking measurements of the newborn's head."

4. "Your newborn can be fitted for a helmet to reshape their head."

Page Ref: 695

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to assess the reflexes of a 5-month-old infant. Which reflexes should the nurse anticipate to document? Select all that apply.

1. Palmar grasp.

2. Stepping.

3. Rooting.

4. Tonic neck.

5. Babinski.

Page Ref: 686-687

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 26.5: Generate the appropriate documentation to describe the assessment findings for infants, children, and adolescents.

MNL Learning Outcome: 26.3. Utilize the appropriate techniques and tools for physical assessment of infants, children, and adolescents.

The mother of a toddler-age client expresses concern about the child's lower back curving in and the child's belly sticking out. Which action by the nurse is appropriate?

1. Suggest the mother to buy the child some bigger clothes.

2. Give the mother the first available appointment to see the healthcare provider.

3. Contact the healthcare provider to see if an orthopedic referral is necessary.

4. Reassure the mother that this is normal for a toddler.

Page Ref: 682

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Ante/Intra/Postpartum and Newborn Care

Learning Outcome: 26.1: Describe unique aspects of anatomy and physiology of body systems for infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

The nurse is preparing to elicit the Babinski reflex on a 6-month-old infant. Which technique should the nurse use?

1. Touch the infant's foot at the base of the toes.

2. Turn the infant's head to one side while the infant is supine.

3. Stroke the plantar surface of the foot from the heel to the toe.

4. Hold the infant upright and allow the feet to touch a surface.

Page Ref: 687

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Techniques of Physical Assessment

Learning Outcome: 26.4: Outline the techniques for physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.3. Utilize the appropriate techniques and tools for physical assessment of infants, children, and adolescents.

The nurse is assessing school aged children in a clinic that serves an impoverished community. Which common finding should the nurse anticipate in this population?

1. Chronic illness.

2. Lower weight.

3. Mental health disorders.

4. Developmental delays.

Page Ref: 688

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is reviewing the common foods that cause an allergic reaction in children with a group of parents. Select all that apply.

1. Milk.

2. Eggs.

3. Wheat.

4. Cheese.

5. Shellfish.

Page Ref: 691

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Promotion/Disease Prevention

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

The nurse is preparing to assess a child with fetal alcohol syndrome. Which physical findings should the nurse anticipate? Select all that apply.

1. Facial deformities.

2. Developmental delay.

3. Cardiac defects.

4. Head deformities.

5. Limb deformities.

Page Ref: 691

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

A parent of a young child tells the nurse they are worried that their child has had 4 colds over the past year. Which information should the nurse provide the parent?

1. You need to make sure your child has had the flu shot.

2. Colds are common in young children.

3. Keep your child away from other ill children.

4. Make sure everyone is washing their hands in your household.

Page Ref: 692

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to assess a child with acute gastroenteritis. Which question is the most important to ask the parent?

1. "Has your child been vomiting?"

2. "Has your child had diarrhea?"

3. "Has your child been drinking fluids?"

4. "Has your child been urinating?"

Page Ref: 683

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26.3: Determine questions about infants, children, and adolescents to use for the focused interview.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to assess the musculoskeletal system of a 9-month-old infant. Which finding should the nurse anticipate to include in the documentation?

1. Genu valgum.

2. Genu varum.

3. Lordotic curve.

4. Scoliosis.

Page Ref: 684

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 26.5: Generate the appropriate documentation to describe the assessment findings for infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse assessing the musculoskeletal system of a 4-year-old child observes them rising to a standing position after being supine. Which finding should the nurse be concerned about?

1. The child rises without using arm support.

2. The child reaches out for the parent to pick them up.

3. The child places their hands on the floor and straightens their legs.

4. The child places their hands on their knees and pushes their trunk up.

Page Ref: 685

Cognitive Level: Applying

Client Need & Sub: Physiological Adaptation; Alterations in Body Systems

Learning Outcome: 26.6: Identify abnormal findings in the physical assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to assess an adolescent. Which should the nurse recognize is a common finding?

1. Somatic complaints.

2. Depression.

3. Substance abuse.

4. Eating disorders.

Page Ref: 689

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Health Screening

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.4. Differentiate normal and abnormal variations of infants, children, and adolescents observed during physical assessment.

The nurse is preparing to assess a 5-year-old child using Piaget's theory of cognitive development. Which stage should the nurse anticipate to use?

1. Formal Operations.

2. Concrete Operations.

3. Preoperational Skills.

4. Sensorimotor.

Page Ref: 690

Cognitive Level: Understanding

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

The nurse notes an orange hue on the skin of a 11-month-old infant. Which focused assessment question should the nurse ask the parent?

1. "Has your child been sick?"

2. "Does your infant take any medications?"

3. "Can you tell me what foods the baby eats?"

4. "Does your infant attend a childcare center?"

Page Ref: 691

Cognitive Level: Applying

Client Need & Sub: Health Promotion and Maintenance; Developmental Stages and Transitions

Learning Outcome: 26.3: Determine questions about infants, children, and adolescents to use for the focused interview.

MNL Learning Outcome: 26.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of infants, children, and adolescents.

Document Information

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DOCX

Chapter Number:

Created Date:

Aug 21, 2025

Chapter Name:

Chapter 26 Infants, Children, and Adolescents

Author:

Cynthia Fenske

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Test Bank Answers Infants, Children, and Adolescents Ch.26

Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)

Chapter 26 Infants, Children, and Adolescents

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