Chapter 27: Children and Adolescences

The nurse has assessed the head circumference (HC) of an 18-month-old during a regular checkup. The nurse should compare the percentile of the child's HC to which of the following?

The child's height and weight percentiles

A child tells the school nurse that she vomited and her "tummy hurts bad." She points to the lower right quadrant of the abdomen. These symptoms lead the nurse to be concerned with what condition?

Appendicitis

The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the following should the nurse suspect?

Appendicitis

The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child?

24 breaths/minute

A mother brings her 12-year-old son to the clinic for a routine physical. The mother tells the nurse that her son seems to be growing taller recently. The nurse should instruct the mother that the peak growth spurt in boys usually occurs by age

14 years

The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child?

Actively engage the child in play.

The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital?

An infant is placed in a forward facing car seat.

A 6-year-old boy is brought to the emergency department by his parents, who state that he has been crying and saying his tummy hurts. Which method would be most appropriate initially to assess the problem?

Ask the child to point with one finger where it hurts.

A school nurse plans to test hearing acuity in students who range between kindergarten and sixth grade. What would be most appropriate method?

Audiometry

A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe?

Children typically have higher pitched heart sounds.

Tommy, an 18-month-old, is seen in the clinic for otitis media. The nurse notes that Tommy coos and babbles but does not say distinct words. Which nursing diagnosis is most appropriate?

Delayed growth and development

The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate?

Denver Developmental Screening

The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?

It is likely a breast bud which is a normal finding at this age.

The nurse is meeting the parents of an ill child for the first time and is preparing to perform the health interview. In addition to gathering health data, what additional goal should the nurse prioritize during this interaction?

Foster trust with the child's parents.

While attempting to auscultate heart sounds a 2-year old client pushes the nurse's hand away. What should be done to facilitate this assessment?

Give the child something to hold in each hand

One of the Healthy People goals for children and adolescents is to reduce the proportion who are overweight or obese. What intervention by the school nurse would help to meet this goal?

Go to each class and give a presentation with discussion of healthy snacking and exercise.

Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child?

Have the child blow a pinwheel.

While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of

Iron

It is often difficult to assess the location of pain in a child because generally children cannot

Isolate their pain

While performing an assessment on a 14 year old, the nurse notes the child has limited range of motion of the neck. The nurse recognizes this could be caused by what?

Meningitis

Which information would a nurse include when taking a health history on a child, but omit with an adult?

Prenatal history

A nurse has completed an assessment of a school-age child. The nurse has identified several "soft signs" of potential neurologic impairment. How should the nurse best interpret these findings?

Recognize that the findings may or may not indicate the presence of a neurologic problem.

Which of the following is the most accurate method of determining the length of a child under 24 months of age?

Recumbent length measured in the supine position

Which test would the nurse perform to detect the presence of a congenital cataract?

Red reflex

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage?

Relative sexual indifference and interaction with same-sex peers

After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be

Stage 2

A 14-year-old girl comes to the clinic and requests to be seen for suspicion of a sexually transmitted disease (STD). What is the nurse's responsibility for treatment of this adolescent?

The nurse understands that it is not necessary to have parental consent to treat an STD in a child 13 years or older.

The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding?

This is a normal finding for a toddler.

The nurse determines the heart rate of 100 beats per minute for a 5-year-old client as being:

Within normal limits