Chapter 10: Health Assessment of Children
4. The nurse performing a health history on a child asks the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question? A) Endocrine B) Genitourinary C) Hematologic D) Neurologic
Ans: A Feedback: Indicators of problems with the endocrine system include increased thirst, excessive appetite, delayed or early pubertal changes, and problems with growth. For the genitourinary system the nurse would assess urinary patterns and genitals. For the hematologic system the nurse would assess lymph nodes, skin color, and bruising. Signs of neurologic problems include numbness, tingling, difficulty learning, altered mood or ability to stay alert, tremors, tics, and seizures.
17. The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate? A) Radial B) Brachial C) Pedal D) Femoral
Ans: A Feedback: In a child younger than 2 years of age, the radial pulse is very difficult to palpate, whereas the pedal, brachial, and femoral pulses are usually easily palpated
28. The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty? A) Appearance of pubic hair around 11 to 13 years old B) Swelling or redness of the labia minora C) Presence of labial adhesions D) Lesions on the external genitalia
Ans: A Feedback: Infants and young girls (particularly those of dark-skinned races) may have a small amount of downy pubic hair. Otherwise, the appearance of pubic hair indicates the onset of pubertal changes, sometimes prior to breast changes. Pubic hair generally begins to appear by age 11 years, with age 13 being the latest. Redness or swelling of the labia may occur with infection, sexual abuse, or masturbation. Lesions on the external genitalia may indicate sexually transmitted infection.
15. The nurse is assessing heart rate for children on the pediatric ward. What is a normal finding based on developmental age? A) An infant's rate is 90 bpm. B) A toddler's rate is 150 bpm. C) A preschooler's rate is 130 bpm. D) A school-age child's rate is 50 bpm.
Ans: A Feedback: The normal heart rate for an infant is 80 to 150 bpm, for a toddler is 70 to 120 bpm, for a preschooler is 65 to 110 bpm, and for a school-age child is 60 to 100 bpm.
22. The nurse is conducting a routine health assessment of a 3-month-old boy and notices a flat occiput. The nurse provides teaching and emphasizes the importance of tummy time. Which response by the mother indicates a need for further teaching? A) "I should have him sleep on his tummy." B) "I need to watch him during his tummy time." C) "I need to change his head position while he is in an upright chair." D) "His head has flattened due to the pressure of his head position."
Ans: A Feedback: The nurse needs to emphasize that the boy must be observed and awake during the recommended "tummy time" and to remind the mother that the baby should still sleep on his back. The other statements are correct.
10. The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order? A) Inspection, palpation, percussion, auscultation B) Inspection, percussion, palpation, auscultation C) Palpation, percussion, inspection, auscultation D) Inspection, auscultation, palpation, percussion
Ans: A Feedback: The physical examination of children, just as for adults, begins with a systematic inspection: checking color, warmth, characteristics, and texture visually and smelling for any odor. Palpation follows inspection to validate observations. Next percussion is used to determine the location, size, and density of organs or masses. The stethoscope is used last to auscultate the heart, lungs, and abdomen.
8. Which would be least effective in gaining the cooperation of a toddler during a physical examination? A) Tell the child that another child the same age wasn't afraid. B) Allow the child to touch and hold the equipment when possible. C) Permit the child to sit on the parent's lap during the examination. D) Offer immediate praise for holding still or doing what was asked.
Ans: A Feedback: Toddlers are egocentric, and telling the toddler how well another child behaved or cooperated probably will not help gain this child's cooperation. Allowing the child to touch and hold the equipment, permitting the child to sit on the parent's lap during the exam, and offering praise immediately for cooperating would foster cooperation.
5. The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which topics might the nurse include? Select all answers that apply. A) The child's toileting habits B) Use of car seats and other safety measures C) Problems with growth and development D) Prenatal and perinatal history E) The child's race and ethnicity F) Use of supplements and vitamins
Ans: A, B, F Feedback: The functional history should contain information about the child's daily routine, such as toileting habits, safety measures, and nutrition. Problems with growth and development would be covered in the developmental history. Prenatal and perinatal history is assessed in the past health history and the child's race and ethnicity is part of the demographics.
18. While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as what grade? A) Grade 1 B) Grade 2 C) Grade 3 D) Grade 4
Ans: B Feedback: A grade 2 murmur is soft and quiet and is heard each time the chest is auscultated. A grade 1 murmur is barely audible and is heard at some times and not at other times. A grade 3 murmur is audible with intermediate intensity. A grade 4 murmur is audible and accompanied by a palpable thrill.
24. The nurse is inspecting the fingernails of an 18-month-old girl. What finding indicates chronic hypoxemia? A) Nails that curve inward B) Clubbing of the nails C) Nails that curve outward D) Dry, brittle nails
Ans: B Feedback: Clubbing of the nails indicates chronic hypoxemia related to either respiratory or cardiac disease. Nails that curve inward or outward may be hereditary or linked with injury, infection, or iron-deficiency anemia. Dry, brittle nails may indicate a nutritional deficiency.
7. The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child? A) Keep up a running dialogue with the caregiver, explaining each step as you do it. B) Include the child in all parts of the examination; speak to the caregiver before and after the examination. C) Speak to the child using mature language and appeal to his or her desire for self-care. D) Address the child by name; speak to the caregiver and do the most invasive parts last.
Ans: B Feedback: For a school-age child, the nurse should include the child in all parts of the examination, and speak to the caregiver before and after the examination. For a newborn the nurse should keep up a running dialogue with the caregiver, explaining each step as it is done. The nurse should speak to the early teen using mature language and appeal to his or her desire for self-care. For an infant, the nurse should address the child by name, and speak to the caregiver and do the most invasive parts last
13. The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In order to get an accurate reading, what does the nurse need to do? A) Pull the earlobe back and down B) Direct the infrared sensor at the tympanic membrane C) Pull the earlobe down and forward D) Remove any visible cerumen from inside the ear canal
Ans: B Feedback: The accuracy of tympanic temperature reading is dependent upon appropriate technique. The nurse needs to be sure to direct the infrared sensor at the tympanic membrane. Since the child is older than age 3, the earlobe does not need to be pulled back and down. The nurse would not remove earwax from inside the ear canal.
12. The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child? A) Oral thermometer B) Axillary method C) Temporal scanning D) Rectal route
Ans: B Feedback: The axillary method may be used for children who are uncooperative, neurologically impaired, or immunosuppressed or have injuries or surgery to the oral cavity. Since the child is crying and uncooperative, the oral method would not be a good choice. The accuracy of the temporal method may be affected by excessive sweating. The rectal route is invasive, not well accepted by children or parents, and probably unnecessary with the modern alternative methods now available.
29. A teenage patient tells the nurse that she is being abused by her boyfriend but she doesn't want her parents to know because they won't let her see him any longer. What is the best response by the nurse? A) "It's my responsibility to tell your parents if you are in danger." B) "I understand your fear, but I am obligated to be sure your parents know you are in danger. Would you like for us to talk to them together?" C) "I won't tell them this time, but I must inform you that legally I must inform your parents if abuse is occurring. Next time it happens I will have to tell them." D) "You need to tell them because the abuse isn't going to get any better. It will only escalate no matter what your boyfriend says."
Ans: B Feedback: The most empathetic and informative response is recognizing the teen's fear. This response also establishes trust by letting the patient know what the nurse's responsibility is while also offering support by talking to the parents with the teen. Responding that the nurse won't inform the parents this time is incorrect because the nurse is legally bound to notify the parents if the child is in danger, as in the case of abuse
1. The nurse is conducting a health history for a 9-year-old child with stomach pains. What is a recommended guideline when approaching the child for information? A) Wear a white examination coat when conducting the interview. B) Allow the child to control the pace and order of the health history. C) Use quick deliberate gestures to get your point across. D) Do not make physical contact with the child during the interview.
Ans: B Feedback: The nurse should elicit the child's cooperation by allowing him or her control over the pace and order of the health history, or anything else that the child can control while still allowing the nurse to obtain the information needed. A white examination coat or all-white uniform may be frightening to children, who may associate the uniform with painful experiences or find it too unfamiliar. The nurse should use slow deliberate gestures rather than very quick or grand ones, which may be frightening to shy children. The nurse should make physical contact with the child in a nonthreatening way at first by briefly cuddling newborns before returning them to caregivers, laying a hand on the head or arm of toddlers and preschoolers, and warmly shaking the hand of older children and teens to convey a gentle demeanor.
23. The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy's reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action? A) Repeat the reading with the oscillometric device. B) Repeat the blood pressure reading using auscultation. C) Measure the blood pressure in all four extremities. D) Measure the blood pressure with a Doppler.
Ans: B Feedback: The nurse should repeat the reading using auscultation. The nurse should not use the Doppler ultrasound method in this circumstance. The nurse would only measure the blood pressure in all four extremities with a child presenting with cardiac complaints.
2. For which children would the nurse conduct an immediate comprehensive health history? A) A child who is brought to the emergency room with labored breathing B) A child who is a new client in a pediatric office C) A child who is a routine client and presents with signs of a sinus infection D) A child whose condition is improving
Ans: B Feedback: The purpose of the examination will determine how comprehensive the history must be. A comprehensive history would be performed for a new child in a pediatric office or a child who is admitted to the hospital. Also, if the physician or nurse practitioner rarely sees the child or if the child is critically ill, a complete and detailed history is in order, no matter what the setting. The child who has received routine health care and presents with a mild illness may need only a problem-focused history. In critical situations, some of the history taking must be delayed until after the child's condition is stabilized.
30. The nurse is collecting information from the parents of a 3-year-old child about her sleeping patterns. Which question by the nurse will best elicit information from the parents? A) "How are things going at home?" B) "Is your child sleeping well at night?" C) "How many hours does your child sleep at night?" D) "What time does your child go to bed at night?"
Ans: C Feedback: Asking an open-ended question will provide the most opportunity for data to be collected from the parents. Asking how things are going at home is vague and may or may not give the needed information. Asking if the child is sleeping well is problematic as the term "well" is subjective and may be interpreted differently by different individuals. Asking when the child goes to bed is a broad question that may not provide the needed information about the quantity of sleep being achieved by the child each night.
26. Assessment reveals that a child weighs 73 pounds and is 4 feet, 1 inch tall. The nurse calculates this child's body mass index as: A) 19.1 B) 20.7 C) 21.4 D) 24.5
Ans: C Feedback: Body mass index is determined by dividing the child's weight (in pounds) by the child's height (in inches) squared and then multiplying this figure by 703. Thus, 73 lb divided by (49 inches × 49 inches) equals 0.0304 multiplied by 703 equals 21.37 or 21.4
21. The nurse is assessing the neck of an 8-year-old child with Down syndrome. Which finding would the nurse expect during the examination? A) Webbing B) Excessive neck skin C) Lax neck skin D) Shortened neck
Ans: C Feedback: Lax neck skin may occur with Down syndrome. Webbing or excessive neck skin folds may be associated with Turner syndrome. A shortened neck is expected in a child younger than age 4.
14. A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate? A) Oral B) Tympanic C) Rectal D) Axillary
Ans: C Feedback: Obtaining the child's temperature via the rectal route would be least appropriate because the child has diarrhea, and insertion of the thermometer might traumatize the rectal mucosa. Additionally, the rectal route is highly invasive and a child of this age fears body invasion. Using the oral route might be problematic due to the child's age and inability to cooperate, especially in light of the child's vomiting. However, it would not be as dangerous as obtaining a rectal temperature. The tympanic or axillary method would be the most appropriate method.
6. The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination? A) The child B) The parents C) Chief complaint D) Developmental age
Ans: C Feedback: The next step after the health history is the physical examination. It should focus on the chief complaint or any of the systems that engaged the nurse's critical thinking while obtaining the history. The child and parents are involved in the assessment but the focus is on the health problem. The nurse should conduct a physical examination with the child's developmental age in mind
19. The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond? A) "Your daughter has acrocyanosis; this is causing her blue hands and feet." B) "Let's watch her carefully to make sure she does not have a circulatory problem." C) "This is normal; her circulatory system will take a few days to adjust." D) "This is a vasomotor response caused by cooling or warming."
Ans: C Feedback: The nurse should tell the parents that this is normal and that the baby's circulatory system is adjusting to extrauterine life. Using the technical term "acrocyanosis" would most likely scare the parents. Telling the parents that the child may have a circulatory problem is inaccurate as this is a normal variation. Acrocyanosis and the mottling caused by cooling and warming are two different variations.
11. The nurse is examining the posture of a male toddler and notes lordosis. What would be the appropriate reaction of the nurse to this finding? A) Explain that the child will need a back brace. B) Refer the toddler to a physical therapist. C) Do nothing; this is a normal condition for toddlers. D) Notify the primary care physician about the condition.
Ans: C Feedback: The toddler demonstrates lordosis (swayback) and bowlegs, with a relatively large head and protuberant belly. This is a normal condition and requires no further attention.
3. The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which question would be most likely to elicit valuable information? A) 'Do you like your new school?' B) 'Are you happy with your teacher?' C) 'Do you enjoy reading a book?' D) 'What are your new classmates like?'
Ans: D Feedback: A careful conversation and interview with the child and/or the caregiver will provide important information about the child's health. Depending on the intent of the health assessment, many of the questions will be direct, and many will require the caregiver or child to answer simply "yes" or "no." In other than emergency situations, though, asking open-ended questions such as 'What are your classmates like?' offers an excellent opportunity to learn more about the child's life
25. The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old girl. The nurse understands that falsely high readings may be associated with which situation or condition? A) A nonsecure connection B) Cold extremities C) Hypovolemia D) Anemia
Ans: D Feedback: Falsely high readings may be associated with anemia. Falsely low readings may be associated with cold extremities, hypovolemia, and a nonsecure connection
9. The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? A) Heart B) Abdomen C) Lungs D) Throat
Ans: D Feedback: If the infant is asleep, the nurse should auscultate the heart, lungs, and abdomen first while the baby is quiet. The nurse performs the assessment in a head-to-toe manner, leaving the most traumatic procedures, such as examination of the ears, nose, mouth, and throat, until last.
20. A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate? A) Increased intracranial pressure B) Overhydration C) Dehydration D) These are normal findings.
Ans: D Feedback: It is common to see the fontanel pulsate or briefly bulge if a baby cries. Overhydration or increased intracranial pressure would cause a persistent bulging. Dehydration would cause the fontanel to be sunken
27. The nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. What may be associated with renal disorders? A) Swollen nipples upon inspection of a newborn's breasts B) Tender nodule palpated under the nipple of a 10-year-old C) Observation of enlarged breast tissue in a male adolescent D) Observation of a supernumerary nipple along the mammary ridge
Ans: D Feedback: Supernumerary nipples are usually of no concern as they do not change over time, but they may be associated with renal disorders. Newborns of both genders may have swollen nipples from the influence of maternal estrogen, but by several weeks of age the nipples should be flat. A tender nodule palpated just under the nipple confirms pubertal changes and is a normal finding. Adolescent boys may develop gynecomastia (enlargement of the breast tissue) due to hormonal pubertal changes. When the hormone levels stabilize, male adolescents then have flat nipples.
16. The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child's heart rate will be in what ranges? A) 80 to 150 bpm B) 70 to 120 bpm C) 65 to 110 bpm D) 60 to 100 bpm
Ans: D Feedback: The normal heart rate for a school-age child is 60 to 100 bpm, for an infant is 80 to 150 bpm, for a toddler is 70 to 120 bpm, and for a preschooler is 65 to 110 bpm
