Health Assessment of Children

When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history?

"Have you heard that some teens like to smoke? Have you tried this?"

The nurse is measuring the head circumference of a 1-year-old infant during a well-child visit. The parent asks the nurse why this assessment is being performed. Which response will the nurse provide to the parent?

"Head circumference is typically assessed until age 2 or 3 to help determine if growth is appropriate."

The nursing students are learning how to perform a health assessment on a pediatric client. The nursing instructor identifies a need for further teaching when a student states:

"I should take blood pressure on a child beginning at age 2 years."

The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement?

"My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."

The nurse is obtaining a health history on a toddler and asks the parents about their health history, the health history of their other children, and of their parents' health history. The parents ask the nurse why this information is necessary. What is the best response by the nurse?

"The information can alert us to any disease process that might run in families."

The nurse is obtaining health information from the parents of a 3-year-old. Which information is of most concern to the nurse?

"We are renovating an old farmhouse built in the early 1900s."

A nurse is interviewing a parent regarding the 2-year-old child's recent illness. The nurse would like the parent to elaborate about any symptoms of the illness noticed. Which would be the most effective question for the nurse to ask the parent in this situation?

"What symptoms has your child exhibited?"

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?

"You should auscultate all four quadrants for a full minute each."

A nurse is reviewing the physical exam of a child. The nurse notes that the child's deep tendon reflexes were normal, because they were graded as:

2+

Blood pressure monitoring becomes part of the routine health assessment at what age and older?

3 years

The nurse is measuring the head circumference of a child during a well-child visit. Until which age should the nurse take this measurement?

36 months

A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?

96.6°F (35.8°C)

The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?

A delay or lack of clear, understandable speech pattern

A nurse is assessing a 3-year-old child in the local health clinic. The child has a persistent cough on examination. Based on the age of the child, which muscle would the nurse view to assess respiratory status?

Abdominal muscle

A 5-year-old child is being seen at the ambulatory care clinic for a well-child visit. The child is hiding behind his mother. What initial action by the nurse is indicated?

Allow the child to remain "hidden" during the initial part of the interview.

The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with reports of a backache. Which initial action by the nurse is most appropriate?

Ask the child when the pain started.

A nurse is performing a physical examination on a newborn. Which assessment should the nurse include?

Axillary temperature, femoral pulse, head circumference

The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?

Between the sternum and the left nipple

The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take?

Demonstrate the appropriate technique.

A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first?

Details about the fever

A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

Determining the chief complaint

When assessing heart sounds on a high school athlete, the nurse hears a "lub d-dub" sound which is associated with inspiration. What action will the nurse take?

Document the findings as normal.

The registered nurse (RN) observes the unlicensed assistive personnel (UAP) take a rectal temperature on a 6-month-old client diagnosed with diarrhea. Which action by the RN is appropriate?

Educate the UAP on when to avoid taking rectal temperatures.

The nurse is assessing a 4-year-old child who reports having ear pain. What would the nurse incorporate into the assessment?

Grasp the pinna and pull up and back gently in order to assess the ear.

A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading?

Have you kept the child up to date on all of the immunizations suggested?

The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing?

Moro

The nurse is collecting data on a 3-year-old child whose caregiver is present. Which action should the nurse take?

Show the caregiver the process for collecting a urine specimen and ask the caregiver to help the child.

When performing an assessment for scoliosis the nurse asks the child to let both arms hang to the sides. Which observations would be an indication the child requires further screening? Select all that apply

The elbows fall below the level of the iliac crest. The elbows are not at the same level. How straight the child is standing The child leans toward one side.

The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?

The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.

A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. What will the nurse need? Select all that apply.

Thermometer Stethoscope Tongue depressor Ophthalmoscope

The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct?

These lesions will normally fade as the child ages.

The nurse collects a client history including biographical data regarding the child being admitted. Which responsibility is most important related to the data collected?

This information is part of the legal record and should be treated as confidential.

The nurse is doing an assessment of a 10-year-old girl. She whispers the girl's name from behind the girl. Which cranial nerve is the nurse assessing for?

VIII

The nurse conducts the physical examination of a child. When would the nurse expect to examine the child's ears?

after completing all other parts of the exam

The nurse is assisting with the physical examination on a sleeping10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment?

back and extremities; head and neck; then the ears, nose, mouth, and eyes

The nurse is examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include? Select all that apply.

color location size distribution

The nurse is performing an assessment on a teen's clavicle strength. The teen is asked to shrug and raise the shoulders while the nurse applies gentle pressure to them. When documenting the findings, this should be identified as an assessment of which cranial nerve?

cranial nerve XI

A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:

document as a normal finding.

When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom?

localized or generalized

The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond?

"Let's see if I can find some puppies or kittens."

A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his parent. Which statement by the parent should the nurse prioritize for further investigation after noting the father has a history of alcohol use disorder?

"Our next door neighbor is older than my son, and he drinks when they hang out together."

The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature?

"Rectal temperatures should not be taken on a child with diarrhea."

The nurse is assessing a 6-month-old child. The mother asks when the soft area in her child's head will go away. What is the best response by the nurse?

"The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age."

The nurse is preparing to perform a physical examination of a toddler. Which is the preferred location to complete the assessment?

"There are some things I may need to share with your parents or physician."

The nurse brings a 2-day-old newborn into the mother's room in the postpartum unit. The mother voices concern that the newborn's hands and feet "look a little blue." Which response by the nurse is best?

"This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."

The nurse is preparing to see a 14-month-old child and needs to establish the chief purpose of the visit. Which approach with the parents would be best?

"What can I help you with today?"

When obtaining information from a teen concerning the reason for seeking health care, which question would be most important?

"What health concerns are you having?"

The nurse is performing an assessment of the genitalia of a 15-year-old male. The nurse notes that the pigment of the skin of the scrotum is much lighter than the rest of the client's skin color. What is the nurse's best action?

Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin.

As part of a class assignment a nursing student will teach fellow classmates how to conduct a physical assessment on an infant. What priority information should the student teach?

Assess the heart and lungs first.

The nurse is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client?

Blood pressure recording

A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database?

Immunization record

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

The nurse is trying to establish a trusting relationship with an 8-year-old who was newly admitted for testing related to abdominal pain. Which actions by the nurse demonstrate effective actions in developing this relationship?

The nurse allows the child to decide whether she will auscultate the heart or lungs first. The nurse sits down and talks to the child at eye level. The nurse asks the child about school, hobbies, friends, and interests. The nurse encourages the child to tell the nurse how they feel and to point out areas that may be painful.

The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply.

The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting.

A nurse is assessing a 5-day-old infant and documents a positive Babinski sign. Which finding did the nurse observe?

dorsiflexion of the great toe with fanning of other toes

During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition?

meningeal irritation

When doing a health assessment on a child, the nurse should include a physical assessment. What should the nurse assess first when performing the physical assessment?

respirations

The emergency department nurse is caring for a child who is showing signs of anaphylaxis. The nurse evaluates how comprehensive the history of the child should be and determines that which action takes priority?

stabilizing the child's physical status

The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?

swollen labia minora

The nurse is taking vital signs on a 6-month-old infant. The caregiver reports that over the past 12 hours, the infant has had vomiting, diarrhea, and has been pulling on the ears. Which method(s) would be appropriate for taking this infant's temperature? Select all that apply.

temporal axillary

Where is the point of maximal impulse (PMI) found in a 5-year-old child?

the fourth intercostal space

The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately?

visible peristaltic waves