N138 Chp 4 Communication & Physical Assessment
The nurse is taking a health history of a child. At the beginning of the interview one of the parents says, "She was born 6 weeks premature." In what section of the health history should this information be recorded? 1 Past history 2 Family history 3 Chief complaint 4 Review of systems
1 Past history is the section of the health history in which information related to the patient's previous illnesses, injuries, or operations is recorded. Family history is the section in which information about the child as an individual and member of a family is recorded. The chief complaint is the main reason that a patient is seeking professional health attention. The review of systems section is the section in which potential health problems are recorded.
During a physical assessment the nurse notes that the child's height and weight are below the 5th percentile and that the child has pale skin; stringy, dull, dry, thin hair; and a flat abdomen. The child also exhibits generalized muscle wasting. The parent reports not having enough money to buy groceries several times a month. In light of these clinical findings, of what does the nurse suspect the child has a deficiency? 1 Zinc 2 Protein 3 Sodium 4 Vitamin A
2 A deficiency in protein is evidenced by low percentiles in height and weight on the growth charts; stringy, friable, dull, dry, thin hair; and muscle wasting. Zinc deficiency manifests as scaly dermatitis, lesions around the nares, and a diminished sense of taste. Sodium deficiency is manifested by weakness, pain, and cramps. Vitamin A deficiency is evidenced by skin that is hardened or scaling, as well as dental carries.
The nurse is performing an assessment of a neonate. Which body site does the nurse choose to safely and accurately obtain a neonate's temperature? 1 The nurse places the tip of the thermometer under the tongue. 2 The nurse places the tip of the thermometer in the axilla. 3 The nurse places the tip of the thermometer on the tongue. 4 The nurse places the tip of the thermometer into the ear
2 Axillary and rectal routes are usually recommended to assess body temperature in children up to 2 years of age. The nurse places the tip of the thermometer in the axilla. The oral route is not recommended for neonates; it is used for measuring temperature in children more than 2 years of age. To measure body temperature through the oral route, the nurse places the tip of the thermometer under the tongue. The nurse does not place the thermometer on the tongue, because it does not help in recording the temperature. Because the ear canal in neonates has a smaller diameter, inserting the thermometer in the ear can be painful to the child. Thus, it is not used for measuring body temperature in neonates.
What is the term used to describe the reason for the child's visit to the clinic or hospital? 1 Present illness 2 Chief complaint 3 Current condition 4 Review of symptoms
2 Chief complaint is the term used to describe the reason for the child's visit to the clinic or hospital. Present illness is the narrative of the chief complaint from its earliest onset through its progression to the present. Current condition is not a term used in the assessment. Review of symptoms is a specific review of each body system following an order similar to that of the physical examination.
The nurse is assessing skin turgor in a child. The nurse grasps the skin of the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended, or tented, for a few seconds and then slowly falls back on the abdomen. The nurse, drawing on knowledge of the assessment of skin turgor, interprets this finding to indicate what? 1 The child is properly hydrated. 2 The child has poor skin turgor. 3 The tissue shows normal elasticity. 4 The assessment is done incorrectly.
2 Tenting is the term for an indication of poor skin turgor. In normal elasticity the skin returns immediately to its original position. If the child is properly hydrated, the skin is elastic. The correct way to assess turgor is to grasp the skin of the abdomen between the thumb and index finger, pull it taut, and quickly release it. Test-Taking Tip: Do not read too much into the question or worry that it is a "trick." If you have nursing experience, ask yourself how a classmate who is inexperienced would answer this question from only the information provided in the textbooks or given in the lectures.
What is an important part of establishing therapeutic communication with adolescents? 1 Using nonverbal techniques 2 Communicating through transition objects 3 Building a foundation for a trusting relationship 4 Explaining procedures using short sentences and simple words
3 Building a foundation for a trusting relationship is an important part of establishing therapeutic communications with adolescents. Many adolescents have a difficult time understanding nonverbal cues; therefore this is not an important part of therapeutic communication with adolescents. Communicating through transition objects, such as dolls or toys, and using short sentences with simple words are both helpful strategies for use with younger children. STUDY TIP: You have a great resource in your classmates. We all have different learning styles, strengths, and perspectives on the material. Participating in a study group can be a valuable addition to your nursing school experience.
What are some signs of information overload in a patient or family member? 1 Asking direct questions 2 Requesting an interpreter 3 Frequently looking at the clock 4 Directing the focus of discussion
3 Frequently looking at the clock is a sign of information overload in a patient or family member. Asking direct questions, requesting an interpreter, and directing the focus of discussion are not signs of information overload; they are ways to enhance communication by engaging the patient in the conversation.
When taking a child's blood pressure the nurse should understand that the most important factor in accurately measuring blood pressure is which of the following? 1 That blood pressure is stable throughout the lifespan 2 How the Korotkoff sounds can be affected by pressure on the antecubital fossa 3 How choosing the appropriate cuff size most accurately reflects radial arterial pressure 4 That blood pressure measuring devices have no effect on the accuracy of the measurement
3 Researchers have found that the selection of a cuff with a bladder with equal to 40% of the upper arm circumference most accurately reflects directly measured radial arterial pressure. Blood pressure is not stable throughout the lifespan. The Korotkoff sounds can be affected by the pressure on the antecubital fossa, but this is not the most important factor in accurately measuring blood pressure. Blood pressure measuring devices can affect the accuracy of the measurement.
What is the most accurate method of determining the length of a child younger than 12 months of age? 1 Standing height 2 Recumbent length measured in the prone position 3 Recumbent length measured in the supine position 4 Estimation of length to the nearest centimeter or ½ inch
3 The crown-heel length measurement is the most accurate measurement in infants. Infants are generally unable to stand for a height measurement. Measurement should not be estimated, because an accurate measurement is required to determine growth. The infant should be measured in the supine position, not the prone position. Test-Taking Tip: After choosing an answer, go back and reread the question stem along with your chosen answer. Does it fit correctly? The choice that grammatically fits the stem and contains the correct information is the best choice.
What is included in guidelines for a nurse using an interpreter in developing a care plan for an 8-year-old child admitted to rule out epilepsy? 1 Not giving the interpreter too much information so the interview evolves 2 Encouraging the interpreter to ask several questions at a time to make the best use of time 3 Explaining to the interpreter what information must be obtained from the patient and family 4 Discouraging the interpreter and patient from discussing topics that are irrelevant to the original intent of the interview.
3 The interpreter should be given guidance regarding what information must be elicited during the interview. One question should be asked at a time, with sufficient time left for the family to answer. The interpreter should not have to guess what to ask and what information to obtain during the interview. The interpreter should gain as much information from the family as they are willing to share in response to the questions posed. Limits should not be placed on the interview.
The nurse needs to take the blood pressure of a small child. One of the available cuffs is too large, and the other is too small. What is the best nursing action? 1 Use the large cuff. 2 Use the small cuff. 3 Use either cuff, employing the palpation method. 4 Locate the proper size of cuff before taking the blood pressure.
4 To obtain an accurate blood pressure reading it is preferable to use the proper size of cuff. Therefore locating one before taking the blood pressure is the best nursing action. The smaller cuff gives a falsely high blood pressure reading and is not the method of choice. The larger cuff, which may give a falsely low blood pressure reading, is preferable to the smaller cuff, but neither is the method of choice. Auscultation is preferred to palpation.
When a measuring device for assessing a young child's height is not available, how should the nurse accurately measure the length of an 18-month-old child? 1 Have the child stand on the scale to use a wall-mounted unit. 2 Have the child stand next to the wall and mark the child's height. 3 Have someone assist by holding the child's head in midline while the child stands on the wall-mounted unit. 4 Have the child lie on a paper-covered surface, mark the paper at the points for the top of the head and the heels, then measure between these points.
4 When a measuring device for height is not available, the best approach is to have the child lie on a paper-covered surface while the nurse marks the top of the head and the heels and measures between these points. Having a child of this age stand on the scale to use a wall-mounted unit is not appropriate. Having the child stand next to the wall and marking the height is not appropriate. Having someone assist by holding the child's head in midline while the child stands on the wall-mounted unit, is not appropriate at this age.
