HA CoursePoint: Children & Adolescents

During the health assessment interview, which question should the nurse ask the parents of a preschooler to determine the child's level of motor development?

"Can your child run, hop, and skip?"

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child?

5 year old The DDST-II is considered the standard criterion for the developmental evaluation of children aged 1 month to 6 years. It evaluates four developmental areas of interest: personal/social, language, fine motor/adaptive, and gross motor.

A nurse knows that a visual acuity of 20/20 is achieved at what year of age?

6

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. The infant seat should be in the back seat, facing backward, for at least the first year of the child's life. Depending on the construction of the car seat, it may be in the back seat facing backward until the child weighs 30 to 35 lb. A child may face forward after 1 year of age in some types of car seats. At 4 years of age (or at 40 lb), the child may switch from a car seat to a booster seat. The child should be seated and restrained with the automobile's seat belt in such a booster seat, which is designed for use until he or she is at least 49-in. tall. Children who have outgrown the booster seat should ride in the back with a seat belt fastened securely. A child may move to the front seat after 12 years of age if he or she is of adult size. Front air bags have been known to hurt younger and smaller children because of the force with which they are deployed.

A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action?

Apply oxygen via nasal cannula

A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?

Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

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 Denver Developmental Screening Test is used for the developmental evaluation of children aged 1 month to 6 years. It evaluates personal/social, language, fine and gross motor skills. Blackboard and Hirschberg are vision screening exams. The Apgar is calculated at 1 and 5 minutes after birth.

A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding?

Document the finding in the child's chart The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute. The nurse should record this normal finding in the child's chart.

The nurse is collecting the history on a child and discovers that the child has missed a recommended vaccination. What is the nurse's best recommendation?

Encourage a catch up dose as soon as possible.

Upon assessment of the child's eyes, they deviate inward. The nurse recognizes this as what?

Esophoria

The nurse is doing an initial assessment on a school age client admitted to the pediatric unit in sickle cell crisis. When inspecting the eyes, the nurse finds that they are normal. How would the nurse chart these findings?

Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal

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. Breast development begins with a "breast bud" or enlargement of the areola followed by enlargement of breast tissue. The onset of pubertal changes before 8 years in girls and 9 years in boys may be too early and needs further evaluation.

A child is crying when the nurse enters the examination room. What response should the nurse make in order to minimize the child's distress related to the physical examination?

Listen to heart and lung sounds first.

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect?

Mastitis

The nurse is preparing a teaching session for a group of adolescent high school students. What should the nurse include in this teaching? Select all that apply.

Methods to prevent pregnancy Explanation of how pregnancy occurs Transmission and prevention of sexually transmitted infections

While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is

Play

A nurse understands that which sleep pattern is considered normal for a preschooler?

Sleep 11 to 13 hours per day

Which murmur meets the criteria of a innocent murmur? Select all that apply.

Still Pulmonary flow Venous hum

Which principle of child development should guide the nurse's decisions when planning the assessment of a child to best minimize stress?

The child's stage of development is a primary factor in the way the child responds to events.

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

A nurse is observing the throat and tonsils of an 11-year-old girl. Which of the following would represent a normal finding in this client?

Tonsils twice adult size

A mother is telling the nurse in a clinic that her family's former doctor told her that her 6-year-old has a venous hum. The nurse knows that this is considered a benign heart murmur at this age.

True

The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?

Unstable Gait An abnormal neurologic finding in a school-age child is an unstable gait. Bow-legs are common in toddlers. Knock-knees are common in children aged 2 to 7 years. Limping when walking could indicate congenital hip dysplasia in a toddler or ill-fitting shoes

The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?

ask the mother to leave the room Most adolescents older than 13 years prefer to be examined without a parent in the room. Not all adolescents are willing to put a gown so partially uncovering as the examination proceeds to preserve the client's modesty is important. The client may not want the mother to stay during the examination. Young adolescents want to be reassured that everything evaluated is normal.

A child is repeatedly observed using the hand to push the nose upwards and backwards. What associated physical sign should the nurse assess for?

discoloration of the lower orbitopalpebral grooves he described behavior is frequently associated with perennial allergic rhinitis. Edema and discoloration of the lower orbitopalpebral grooves ("allergic shiners") is also a common characteristic of this disorder. Thin lips are associated with fetal alcohol syndrome. An enlarged thyroid gland (goiter) is not a characteristic of perennial allergic rhinitis but rather of hyperthyroidism. Brushfield's spots, abnormal speckling spots on the iris, suggest Down syndrome.

The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to

hop on one foot.

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

isolate their pain

A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that

she can begin bowel training as soon as the child appears ready. Toilet training is a major task of toddlerhood. Readiness is not usual until 18 to 24 months of age. Bowel training occurs before bladder; night bladder training usually does not occur until 3 to 5 years of age.

The nurse is preparing to assess a 5-year-old child. To perform the Hirschberg test, the nurse should

shine a light directly into the pupils.