Chapter 04. Communication and Physical Assessment of the Child and Family

Which of the following data would be included in a health history? (Select all that apply.) a. Review of systems b. Medical insurance carrier c. Past medical history d. Nutritional assessment e. Family medical history

A, C, D, E The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history. Physical assessment and growth measurements are components of the physical examination.

What is the correct sequence used by experienced examiners when performing an abdominal assessment? Begin with the first technique and end with the last. Provide answer using lowercase letters separated by commas (e.g., A, B, C, D). a. Auscultation b. Palpation c. Inspection d. Percussion

C, A, D, B The correct order of abdominal examination is inspection, auscultation, percussion, and palpation. Palpation is always performed last because it may distort the normal abdominal sounds.

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines would the nurse include when using an interpreter? (Select all that apply.) a. Elicit one answer at a time. b. Interrupt the interpreter if the response from the family is lengthy. c. Comments to the interpreter about the family should be made in English. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family.

A, D, E When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. How would the nurse interpret this finding? a. Normal finding b. Abnormal finding, so child needs referral to ophthalmologist c. Sign of possible visual defect, so child needs vision screening d. Sign of small hemorrhages, which will usually resolve spontaneously

a. Normal finding 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.

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action? a. Refer for immediate medical evaluation. b. Continue assessment to determine cause of neck pain. c. Ask parent when neck was injured. d. Record "head lag" on assessment record, and continue assessment of child.

a. Refer for immediate medical evaluation. Hyperextension of the child's head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation; it is not descriptive of head lag. The pain is indicative of meningeal irritation. No indication of injury is present.

A nurse is performing an otoscopic exam on a school-age child. Which direction would the nurse pull the pinna for a child this age? a. Up and back b. Down and back c. Straight back d. Straight up

a. Up and back In children older than 3 years, the ear canal curves downward and forward. As a result, when performing an otoscopic exam, the nurse will pull the pinna up and back before inserting the otoscope.

Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular b. Bronchial c. Adventitious d. Bronchovesicular

a. Vesicular Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate.

Which 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

b. 2 years Satisfactory radial pulses can be used in children older than 2 years. In infants and young children, the apical pulse is more reliable. The apical pulse can be used for assessment at these ages.

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint would be determined? a. Ask for detailed listing of symptoms. b. Ask adolescent, "Why did you come here today?" c. Use Which adolescent says to determine, in correct medical terminology, Which the problem is. d. Interview parent away from adolescent to determine chief complaint.

b. Ask adolescent, "Why did you come here today?" The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A detailed listing of symptoms will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time.

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 whether she is sexually active.

b. Ask her, "Are you having sex with anyone?" Asking the adolescent girl whether 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 to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone.

A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. Which is the nurse testing for? a. Deep tendon reflexes b. Cerebellar function c. Sensory discrimination d. Ability to follow directions

b. Cerebellar function The finger-to-nose test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Each sense is tested separately. Although this test enables the nurse to evaluate the child's ability to follow directions, it is used primarily for cerebellar function.

Which is an important consideration for the nurse who is communicating directly to a young child? a. Speak loudly, clearly, and directly. b. Use transition objects, such as a doll. c. Approach rapidly with a broad smile. d. Initiate contact with child when parent is not present.

b. Use transition objects, such as a doll. Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This will facilitate communication with a child this age. Speaking in this manner will tend to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception will lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children

The nurse accurately relates which body mass index (BMI)-for-age percentile as overweight? a. 10th percentile b. 9th percentile c. 85th percentile d. 95th percentile

c. 85th percentile Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight.

Which strategy by the nurse is most likely to encourage parents to talk about their feelings related to their child's illness? a. Expressing sympathy. b. Asking direct questions. c. Asking open-ended questions. d. Avoiding periods of silence.

c. Asking open-ended questions. Closed-ended questions should be avoided when attempting to elicit parents' feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in helping the relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How would the nurse assess this diet? a. Indicates they live in poverty b. Is lacking in protein c. May provide sufficient amino acids d. Should be enriched with meat and milk

c. May provide sufficient amino acids The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that contain this combination of foods. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.

Which is an appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child? a. Auditory brainstem response b. Behavioral audiometry c. Pure tone audiometry d. Eliciting the startle reflex

c. Pure tone audiometry Conventional audiometry is a behavioral test that measures auditory thresholds in response to speech and frequency-specific stimuli presented through earphones. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.

A nurse is assigned to four children of different ages. In which age group would the nurse understand that body integrity is a concern? a. Toddler b. Preschooler c. School-age child d. Adolescent

c. School-age child School-age children have a heightened concern about body integrity. They place importance and value on their bodies and are oversensitive to anything that constitutes a threat or suggestion of injury. Body integrity is not as important a concern to toddlers, preschoolers, or adolescents.

At which age would the nurse expect the anterior fontanel to close? a. 2 months b. 2 to 4 months c. 6 to 8 months d. 12 to 18 months

d. 12 to 18 months The anterior fontanel normally closes between ages 12 and 18 months. Two to 8 months is too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes between ages 2 and 8 months, the child should be referred for further evaluation.

Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by which age? a. 1 to 2 weeks b. 1 to 2 months c. 3 to 4 weeks d. 3 to 4 months

d. 3 to 4 months Binocularity is usually achieved by ages 3 to 4 months. 1 month is too young. If binocularity is not achieved by ages 6 to 12 months, the child must be observed for strabismus.

The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique might be most helpful? a. Suggest that the child keep a diary. b. Suggest that the parent read fairy tales to the child. c. Ask the parent if the child is always stubborn and uncommunicative. d. Ask the child to draw a picture.

d. Ask the child to draw a picture. Drawing is one of the most valuable forms of communication and tell a great deal about the child because they are projections of their inner self. A diary is appropriate for older children. Reading a fairy tale to the child by the parent is not likely to assist in the nurse/child communication. The nurse is not displaying patience by asking the parent if the child is always stubborn and uncommunicative.

Which is the single most important factor to consider when communicating with children? a. Physical condition b. Nonverbal behaviors c. Presence or absence of a parent d. Developmental level of language

d. Developmental level of language The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child's physical condition is a consideration, developmental level is much more important. The parents' presence is important when communicating with young children but may be detrimental when speaking with adolescents. Nonverbal behaviors will vary in importance, based on the child's developmental level.

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. Which is the best explanation for this? a. A cancerous lesion b. Local scalp infection common in children c. Mild otitis media d. Infection or inflammation close to the site

d. Infection or inflammation close to the site Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes are not usually indicative of cancer. A scalp infection would usually not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed.

During examination of a toddler's extremities, the nurse notes that the child is bowlegged. Which would the nurse recognize regarding this finding? a. Abnormal and requires further investigation b. Abnormal unless it occurs in conjunction with knock-knee c. Normal if the condition is unilateral or asymmetric d. Normal because the lower back and leg muscles are not yet well developed

d. Normal because the lower back and leg muscles are not yet well developed Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk. It usually persists until all their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African-American children.

How does the nurse assess a child's capillary refill time? a. Inspecting the chest b. Auscultating the heart c. Palpating the apical pulse d. Pressing the pad of the fingertip

d. Pressing the pad of the fingertip Capillary refill time is assessed by pressing lightly on the skin to produce blanching, and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary refill time.

Which following parameters correlates best with measurements of the body's total protein stores? a. Height b. Weight c. Skinfold thickness d. Upper arm circumference

d. Upper arm circumference Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the body's fat content