Peds Ch. 32 Prep-U (Let's get this bread)

The nurse is beginning a health history with a 3-year-old child. Which question would the nurse ask the mother first?

"Do you have any concerns about your child?"

The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond?

"For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level."

The nurse is auscultating the lungs of a lethargic, irritable 6-year-old boy and hears wheezing. The nurse will most likely include which teaching point if the child is suspected of having asthma?

"I'm going to have this hospital worker take a picture of your lungs."

A nursing instructor is teaching about taking a health history and how to elicit a chief concern. The instructor realizes a need for further education when a student makes with statement?

"Intensity refers to how often the concern occurs during the day."

The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action?

Heart rate of 120 beats per minute

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

The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first?

Inspection

The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process?

Interviewing the child's caregiver

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

Meningeal irritation

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."

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 needs to calculate the child's body mass index (BMI). The child's weight is 42 kg. The child is 142 cm in height. Calculate the child's BMI using the metric method. Record your answer using a whole number.

21

The student nurse is caring for a child who weighs 48 pounds and is 38 inches tall. Which is the child's body mass index (BMI)?

23

A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do:

24-hour recall.

The nurse is reviewing vital signs taken by the unlicensed assistive personnel on a group of toddlers. Which warrants follow up by the nurse?

Heart rate 60, respiratory rate 31

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?

Take the apical pulse.

All infants should have their head circumference measured at health-assessment visits. Where should the nurse place the tape measure to obtain this measurement?

just above the eyebrows through the prominent part of the occiput

The nurse brings a 2-day-old infant into the mother's room in the postpartum unit. The mother voices concern that her newborn's hands and feet "look a little blue." How should the nurse respond?

"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 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."

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 health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer?

1/4 to 1/2 inch (0.64 to 1.27 cm)

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?

3 years

The nurse is assessing deep tendon reflexes on a child admitted for severe dehydration. The assessment reveals hyperactive reflexes. How should the nurse document this finding?

4+

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 nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?

Count after the child stops crying and is comfortable.

A nurse is assessing an infant's reflexes. The nurse places his or her thumb to the ball of the infant's foot to elicit which reflex?

Plantar grasp

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

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 related to taking a temperature?

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

The nurse is taking the health history of a 15-year-old client. What would be an appropriate way for the nurse to ask about the client's drug use history?

"Some teens like to smoke. Have you tried this?"

The nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information?

"Tell me about your favorite activity at school?"

A nurse is assessing a 3-year-old child. Which would be appropriate ways to approach the child during the exam? Select all that apply.

-Ask the child if he/she would prefer to sit on the parent's lap for the exam. -Give reassurance to the child during the exam.

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 and typically closes anytime up to 18 months of age."

The nurse is obtaining a health history on a 10-year-old child 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 nursing instructor is evaluating assessment techniques of several student nurses while performing assessments of pediatric clients. Which assessment techniques will require further instruction? Select all that apply. You Selected:

-A student organizes assessment equipment by laying all items, such as blood pressure cuff, stethoscope, and otoscope, on the bedside table -A student nurse awakens a sleeping infant in order to adequately assess the heart and lungs

The nurse is conducting a physical assessment on a 2-year-old. What steps are important for the nurse to incorporate in this examination? Select all that apply.

-Allow play with the equipment being used. -Have parents remove the clothing. -Stand on the scale for height and weight.

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

With the child seated on the caregiver's lap.

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

24 months

At what age is measuring occipital head circumference in a child discontinued?

36 months

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.

While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nusre most likely be performing?

Assessing vision

The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. What is the most appropriate way to gather information from the child's caregiver?

Ask the caregiver questions and document the answers.

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

Ask the child when the pain started.

A 12-year-old client comes to the clinic for an annual checkup. The nurse needs to take a health history and perform a physical exam. Which method would be the most appropriate when obtaining the client's health history?

Ask the client if it OK for the parent to be in the room.

The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?

Ask the parents to complete a day history.

The nurse enters a room to perform an assessment and finds the 9-month-old client asleep in the father's arms. Which action will the nurse take first?

Assess the infant's respiratory status

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

Axillary temperature, femoral pulse, head circumference

When preparing to examine a 2-year-old child, which action by the nurse will best establish rapport?

Bend down to the child's eye level to establish contact.

Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?

Closed anterior and posterior fontanels

The nurse is examining the back and spinal area of a 14-year-old female. A small dimple is noted. What action is most appropriate?

Document the finding as normal.

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

The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam?

Examine the child's head and work down to the child's toes.

The caregiver of an infant keeps removing the pulse oximetry sensor claiming it is too tight and hurting her baby. Which response should the nurse prioritize in addressing this situation?

Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin.

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?

Five to 10 per minute

The nurse is assessing the vital signs of several toddlers in the pediatric medical unit. Which findings are of most concern to the nurse?

Heart rate 60 beats per minute; respiratory rate 14 breaths per minute

The nurse is conducting a physical examination of a healthy 6-year-old. Which action should the nurse do first?

Observe the skin for its overall color and characteristics

A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's parent, "What did you do to help your child before coming to health facility?" This is an example of which type of question?

Open-ended

The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment?

Place the tape measure around the head just above the eyebrows.

The nurse is performing an examination of the eyes of a 7-year-old girl. Which finding would indicate that the third cranial nerve is intact?

Pupil constriction in response to light

The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated?

Report the findings to the physician.

During an assessment, a child exhibits an audible high-pitched inspiratory noise, a tripod stance and intercostal retractions. Using SBAR communication, the nurse notifies the health care provider and states which breath sounds that are congruent with the clinical presentation of the child?

Respiratory stridor

The nurse is auscultating the heart of a 6-month-old. Which finding would warrant further investigation?

S1 varies in intensity.

A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate?

School age

A nurse taking a health history of a 2-year-old child and asks the parent if the child is kept in a playpen or given room to run. What does this question help the nurse learn from about the child?

The child's well-being and development

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

The fourth intercostal space.

When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested?

The reflex is diminished.

The mother of 2-year-old triplets is anxious and worried because one of the trio does not seem to be developing at the same rate as the other two. Which assessment finding would lead the nurse to question the need for further diagnostic testing for this child?

The tops of her ears are below the corners of her eyes.

The nurse is assessing a 6-year-old child. The nurse instructs the child, "Let me see all of your pretty white teeth." Which cranial nerve is the nurse assessing?

VII

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 is admiting to the intestive care unit a child who arrives on cardiac monitor, pulse oximeter, and an IV infusion. As the nurse begins collecting data on the child, which nursing interventions should the nurse prioritize?

Verify that the alarms on the monitor are still properly set.

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

Visible peristaltic waves

A nurse has just performed an assessment on a 12-year-old client and has identified a distended bladder that has a hyper-resonant (low, hollow) sound. Which technique did the nurse use to identify this sound?

percussion