PEDS Chapter 10 Health Assessment of Children

Due to casts on both arms, the nurse must measure an 11-year-old client's blood pressure in the thigh. After placing the blood pressure cuff on the thigh, which action by the nurse demonstrates understanding of the procedure?

The nurse places the stethoscope over the popliteal artery The stethoscope should be placed on the artery nearest, but below the blood pressure cuff. pg 284

The nurse is assessing a newborn child. The mother asks why the newborns feet are blue. What is the best response by the nurse?

"Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body." Blueness of the hands and feet, known as acrocyanosis, is normal in babies up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. Although blueness in hands and feet may indicate a lack of oxygen and may be called peripheral cyanosis, acrocyanosis is a normal finding in a newborn. Pallor is defined as paleness, not blueness of skin. Page 290

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 between 9 and 18 months of age." The anterior fontanel typically closes by the age of 9 to 18 months. Fontanels are soft areas on the skull that remain open in infancy to allow for rapid brain growth in the first months of life. This answer is a true statement but does not answer the mother's question. Page 293

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." Obtaining a three-generation health history can help in determining the risk of potential disease processes that have familial tendencies, such as diabetes, heart disease, etc. While the family health history is part of the standard assessment that must be completed, this response does not address the parent's question. Page 275

A 15-year-old female tells the nurse that she is worried that something is wrong with her because her left breast is bigger than her right breast. What is the best response by the nurse?

"As your breasts continue to develop it is not unusual for females to have one breast larger than the other." Female breast development may begin as early as age 8, but starts by age 13 in most girls. Breast development then continues in a characteristic, but usually asymmetric, pattern, with one breast larger than the other throughout the lifespan. Page 300

The nurse is obtaining a functional history during an admission assessment of a 12-year-old child. Which questions would be appropriate for the nurse to ask during this part of the assessment? Select all that apply.

"Can you tell me if you play any sports or participate in any physical activities?" "Do you wear a seat belt any time you are a passenger in a car?" "Do you use a computer or a smart phone?" The functional history should contain information about the child's daily routine. Questions such as the amount of physical activity, car safety, and use of computers and smart phones (including the amount of time on these devices) are included in this assessment. Asking about heart problems is included in the family history assessment, and asking about parents is included in the family composition assessment. pg 276q

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." BMI between the 85th and 95th percentiles for children between the ages of 2 and 20 indicates risk for overweight. BMI greater than the 95th percentile indicates the child is overweight. Informing of the parents of these findings and discussing diet and activity effectively address the issue in a therapeutic way. Page 289

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? When obtaining a health history from teens, the nurse should approach questions about sensitive subjects in a nonthreatening manner. This method may encourage the teen to not be afraid to ask questions and be more open. The other choices are all direct questions that may make the teen apprehensive or discourage them from being truthful when answering. Page 274

A nurse is caring for a very shy 4-year-old girl. During the course of a well child assessment, the nurse must take the girl's blood pressure. Which approach is best?

"Help me take your doll's blood pressure" It is best to approach a shy 4-year-old by introducing the equipment slowly and demonstrating the process on the girl's doll first. Toddlers are egocentric; referring to how another child performed probably will not be helpful in gaining the child's cooperation. The other questions would most likely elicit a "no" response. Page 280

A nurse is caring for a very shy 4-year-old girl. During the course of a well child assessment, the nurse must take the girl's blood pressure. Which approach is best?

"Help me take your doll's blood pressure" It is best to approach a shy 4-year-old by introducing the equipment slowly and demonstrating the process on the girl's doll first. Toddlers are egocentric; referring to how another child performed probably will not be helpful in gaining the child's cooperation. The other questions would most likely elicit a "no" response. Page 280

The nursing students are learning how to perform a health assessment on a pediatric patient. 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." When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years. Page 284

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 nurse should try to gain the youngster's cooperation by playing a funny pretend game using the "puppies or kittens" to engage the child. It is more likely the preschooler would prefer to sit on a parent's lap even though a red chair was offered. Politely asking the child to sit still is respectful but not likely to gain cooperation. Asking permission to look into the child's ear is an invitation for the young preschooler to answer "no." Page 296

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 should address the comment about use of a glass thermometer. These thermometers should be avoided since they contain mercury, which is toxic if the thermometer would break. Tympanic temperature measurement is dependent on several factors, so accuracy is sometimes questionable. Oral electronic thermometers are generally very accurate. Rectal temperatures are usually not necessary due to being invasive. Pag 281

A 14-year-old boy has come to his primary-care physician's office for a routine well-child visit. In reading the child's history, the nurse notes the child's father suffers from alcoholism. If the child's mother makes the following statements, which statement would be important for the nurse to gather further data regarding?

"Our next door neighbor is older than my son, and he drinks when they hang out together." Some diseases and conditions are seen across families and this is important in prevention as well as detection for the child. The caregiver can usually provide information regarding family health history. The nurse should use this information to do preventive teaching with the child and family. Early adolescence is a time when experimental use of substances, especially alcohol and tobacco, might be seen. It would be important to assess the use of substances and follow up regarding the behaviors of the adolescent. Page 276

The nurse is discussing taking a temperature on a child with a group of nursing students in a post-conference setting. Which statement made by the nursing students is most accurate related to taking a temperature?

"Rectal temperatures should not be taken on a child with diarrhea." A rectal temperature should not be taken in the newborn because of the danger of irritation to the rectal mucosa or in children who have had rectal surgery or who have diarrhea. page 283

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 good health history includes open-ended questions that allow the child to narrate their experience. The other questions would most likely elicit a yes or no response. Page 274

A 15-year-old female is being seen for an annual physical examination. The teen asks the nurse if what they talk about will be kept private. What is the appropriate response by the nurse?

"There are some things I may need to share with your parents or physician." Teens value privacy. The determination of what may and may not be kept confidential is based on individual state laws. The nurse may need to divulge certain things. It is best to be honest with a teen concerning the privacy of the interview, assessment and care. pg 273

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." Blueness of the hands and feet, known as acrocyanosis, is normal in babies up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. This response is the best description because it lets the mother know this is not unusual and explains why it is occurring without using medical terminology. Page 291

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?" Asking "What can I help you with?" is very welcoming and allows for a variety of responses that may include functional problems, developmental concerns, or disease. Asking about the chief complaint may not be clear to all parents. Asking if the child feels sick will most likely elicit a yes or no answer and no other helpful details. Asking whether the child has been exposed to infectious agents is unclear and would not open a dialogue. Page 275

The nurse is gathering data from the caregiver of a 3-year-old boy. While in the waiting room, the nurse heard the caregiver say the boy feels nauseated. In interviewing the child's caregiver, what would be the most appropriate initial question for the nurse to ask?

"What caused you to decide to bring your son to the clinic today?" To best care for the child, it is important to get the most complete explanation of what brought the child to the health care setting. Repeating the caregiver's statement regarding the child's chief complaint would be helpful in clarifying that the nurse has correctly heard what the caregiver has said. page 275

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?" When obtaining data from a client, using the appropriate questions is important. Questions should be open-ended to yield the most information. Making questions direct will further refine the information made available. It is important that when interviewing the teen the nurse not promote a condition. Assuming the teen is ill is not appropriate. page 275

What information should be included in an 8-year-old's pediatric history?

Immunizations Immunizations should be included in a pediatric history so it's clear if the child is up to date. The other choices are not critical factors. Page 275

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 The formula used to calculate the English version: ______Weight in pounds________ X 703 height in inches X height in pounds . The correct calculation equals 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. Food intake is best obtained by asking a parent to describe a typical day (24-hour recall), listing what the child ate for each meal and between meals as well. Page 276

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+ Deep tendon reflexes are graded by the strength of the response using the standard scale from 0 to 4+: 0, no response; 1+, diminished or sluggish; 2+, average; 3+, brisker than average; 4+, very brisk, may involve clonus. Page 307

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation?

A bubble behind the tympanic membrane A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation. The other findings are within normal limits.

A nurse is examining the skin of a 15-year-old girl. Which finding would most warrant concern on the part of the nurse?

A very dark mole with an uneven border At least a few acne lesions on the face or back are usually present in an adolescent. Lesions or rashes caused by allergies to cosmetics also may be seen. If a child has a tattoo or body piercing, assess the site for inflammation to be certain an infection is not present. Look carefully for moles that are very dark, have uneven borders, or have recently changed shape as these are signs of melanoma or skin cancer. Page 277

The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?

Adolescents will share more about themselves in a private conversation. Adolescents can provide information about themselves. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers. Page 273

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. Children may be shy when at the physician's office. To allow the child the opportunity to initially be "invisible" may be beneficial to help the child become acclimated to the surroundings. Telling the child to act like a big boy is not indicated and may "shame" the child and hinder the development of rapport between the nurse and the child. Eventually the child's mother may need to place him on the examination table but this should not be the initial action by the nurse. Promise of a small token may not work and should not be used at this time. Page 273

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 write the answers down. The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler. Rather than simply asking the caregiver to fill out a form, it may be helpful to ask the questions and write down the answers. page 273

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. When beginning the interview it is best to ask the child about the health complaints. If additional information is needed the parent should then be consulted. Palpating the back and asking the child to demonstrate movements takes place during the examination portion of the appointment and not the health history portion. Page 273

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 While assessment findings do need to be documented, the nurse should ask the client if this finding has always been present because the scrotum is normally darker in color than the rest of the body's skin. The client is old enough to ask him rather than initially speaking with the parents. pg 304

A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate?

Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed. Teens may be modest and uncomfortable having a physical examination in front of their parents. When possible requests by teens for privacy should be granted. Page 278

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

Axillary temperature, femoral pulse, head circumference When examining newborns, take axillary or temporal temperatures to prevent rupture of rectal mucosa. Be certain to take femoral pulses in newborns to rule out coarctation of the aorta. Include newborn reflexes, head circumference, and an assessment of gestational age as routine parts of the examination. Taking blood pressure is not necessary because this value is unreliable in newborns. page 279

The nurse is obtaining a child's health history. Place the information listed in the order in which the nurse would complete the history.

Biographic data Chief complaint History of present illness Past medical history Family medical history Social and environmental history When conducting a comprehensive pediatric history, the nurse would obtain the information in the following order: biographic data, chief complaint, history of present illness, past medical history, family medical history and social and environmental history. Page 275

Which assessment would you expect to introduce for the first time in the physical examination of a 3-year-old child?

Blood-pressure recording Assessing blood pressure is generally introduced at preschool age. The preschool E-chart is used for vision screening at this age. Page 284

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 By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months. Page 293

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 In the toddler the heart rate may range from 70 to 120 beats per minute. The respiratory rate may range from 20 to 30 per minute. Page 283

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. Respirations should be assessed when the child is resting or sitting quietly because respiratory rate changes significantly when children cry, eat, or become more active. They also breathe more rapidly when anxious or frightened. Counting respirations for a full minute assures accuracy. Infants' respirations are primarily diaphragmatic; therefore, counting abdominal movements promotes accuracy. Placing a stethoscope to count respirations tends to be seen as invasive by a toddler and will result in movement away or an increase in respirations. page 283

The nurse is performing an assessment on a teen's clavicle strength. The teen is asked to shrug and raise their 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 Test shoulder strength and the function of cranial nerve XI in the older child by requesting that the child shrug the shoulders while you apply downward pressure. Cranial nerve VII is responsible for the tongue and facial movements. Cranial nerve IX is responsible for swallowing and salivation. Cranial nerve X is responsible for speech and swallowing. Page 306

A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first?

Details about the fever Health interviews typically begin with a history of the chief complaint, because this is what people want to talk about first and represents a primary health problem. Page 275

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 The normal range for heart rate for a preschooler is between 65 and 110 beats per minute. The normal range for respiratory rate for a preschooler is between 20 and 25 breaths per minute. A heart rate of 120 would be abnormal. Page 283

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 normal pilonidal dimple is sometimes seen at the base of the spine. This finding should be documented. There is no additional study or evaluation of this area indicated at this time. Muscle weakness and asymmetry are not associated with the presence of the dimple, which is benign. Page 306

During a routine physical examination of a 13-year-old female, the nurse notes the presence of a tender nodule just below the nipple on her right breast. Which action by the nurse is indicated?

Document the finding as normal. Adolescent females may have a tender nodule beneath the nipple. This signals the onset of puberty. page 300

During a routine physical examination of a 13 year old female the nurse notes the presence of a tender nodule just below the nipple on her right breast. Which action by the nurse is indicated?

Document the finding as normal. Adolescent females may have a tender nodule beneath the nipple. This signals the onset of puberty. Page 300

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 toes. A preschool or toddler child should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants, the examination starts with the chest, and then proceeds from head to toes. page 280

A 4-year-old girl reports having ear pain. To examine the child's ear, how should the nurse proceed?

Grasp the pinna and pull up and back. The ear is examined in a child younger than 3 years of age by pulling the pinna down and back. In a child over 3 years old, the ear is examined by pulling the pinna up and back. These maneuvers straighten the ear canal so that the tympanic membrane can be visualized. page 296

The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse?

It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally." Light pink macule typically found on the eyelids, nasal bridge, or back of neck are called salmon nevi (or, more commonly, "stork bites"). They usually fade over time, but may never go away completely. A strawberry nevus is a raised reddish papule made of blood vessels (hemangiomas). They recede over time, usually by age 9 years. A nevus flammeus is a dark purple-red flat patch and grows with the child. It is more commonly known as a port-wine stain. Ecchymosis is a purplish discoloration that is more commonly known as a bruise.

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 The physical examination of children, just as for adults always begins with a systematic inspection, followed by palpation or percussion, then by auscultation. Page 281

The nurse is measuring the head circumference of a child. What technique is accurate related to this procedure?

Place the tape measure around the head just above the eyebrows. The head circumference is measured routinely in children to the age of 2 or 3 years or in any child with a neurologic concern. Place a paper or plastic tape measure around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head. During childhood the chest exceeds the head circumference by 2 to 3 inches. Page 289

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 Touching the thumb to the ball of the infant's foot would elicit the plantar grasp reflex. The other reflexes are not elicited by this method. Page 307

The nurse is assessing the growth of a premature infant. What would be the appropriate action by the nurse to complete this assessment?

Plot the infant's weight, height, and length on a growth chart. The assessment for growth for a premature infant entails plotting his or her weight, length, and height on a growth chart, which is then analyzed. If the infant is below the growth curve, they are not growing appropriately and interventions may be needed. The nurse weighing the diapers is checking the intake and output of the infant, as does asking mom if the infant eats enough. Taking vital signs does not relate to growth. pg 289

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 If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment. Page 295

While examining a child, the nurse notes quiet, soft sounds each time the stethoscope is moved over the child's chest. The nurse knows that these are not breath sounds. What actions should the nurse take? Select all that apply.

Record the location and timing of the sounds. Auscultate with the child lying down. Auscultate with the child sitting up. Refer the child for further evaluation. The sounds described are characteristic of a grade 2 heart murmur. The child's heart should be auscultated with the child in two different positions—upright and reclining. Innocent murmurs often disappear when the child's position is changed. Recording the location and timing of the sounds is important to further evaluation and in determining the type and meaning of the murmur. A child with a heart murmur needs further evaluation by an experienced examiner. pg 301

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. Persistent strabismus is normal in newborns. If noted after the age of 6 months it should be evaluated by a pediatric ophthalmologist. This will need to be reported to the physician so that the referral can be made. Page 294

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

Respirations The assessment of respirations should always be done first. Completing other parts of the physical assessment could influence the count of respirations.

The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark?

Salmon nevus A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.

The nurse is preparing to perform an assessment on a child who has recently been diagnosed with a chronic disease. The previous shift nurse reports that the father of the child is not dealing well with the diagnosis and appears to be in the anger phase response to illness. What actions should the nurse take to ensure safety? Select all that apply.

Sit close to the doorway when talking with the child and father. Ask another nurse to assist with the assessment. Approach the child and father in a calm manner, showing empathy for the situation. Sitting close to the doorway allows the nurse the ability to leave the room for assistance in case the father becomes excessively angry or abusive. Taking another nurse into the room will free one of the nurses to exit the room for assistance, if necessary. Empathy shows concern and compassion for the situation, which encourages a therapeutic working relationship between the nurse and father. While security may be notified of the potential need for their assistance, standing outside the room is likely to fuel the anger of the father. The nurse should speak and make eye contact with both the child and father to show interest in both parties. Page 273

The nurse is collecting information from a 14-year-old female who was brought to the clinic for a well-child visit by her mother. Which techniques would be most beneficial in this process?

Speak directly to the teen when making inquiries. Sit down facing the teen during the data collection period. When caring for teens it is important to establish a rapport. Questions should be directed to the teen. Sitting when obtaining the health history information is beneficial. It helps to promote comfort between the nurse and client. Parents and teens should be allowed to choose who is present during the physical examination. Page 273

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

Take the apical pulse. Taking the apical pulse with a pediatric stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be used in older children over the age of 10 as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lie close to the skin surface and are easily obliterated. Page 283

The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement or question should the nurse say first to encourage communication?

Tell me about some of your current activities at school. The nurse should first begin with open-ended questions regarding work, hobbies, activities, and friendship in order to make the teen feel comfortable. Once a trusting rapport has been established, the nurse should move on to the more emotionally charged questions. While it is important to assure confidentiality, the nurse should first establish rapport. Page 273

When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history?

The chief complaint of the child The next step in the health assessment is the reason for seeking treatment. Remember to include the child's reason because it may be different from that of the parent or caretaker. Page274

During assessment of a pediatric client, what factor makes the nurse concerned that the pulse oximetry reading is inaccurate?

The child has a hemoglobin reading below normal The hemoglobin of the RBC carries oxygen, so low hemoglobin can cause inaccurate readings of oxygen saturation levels. Pneunomia may cause the oxygen saturation to be low because of poor gas exchange, but the diagnosis will not cause the pulse oximeter measurement to be inaccurate. The probe may be placed on the finger, toe, ear, foot, or forehead. Alarms on pulse oximeters are typically set to alarm when the saturation falls below 90%

The nurse is conducting a physical examination of a 5-year-old girl. The nurse asks the girl to stand still with her eyes closed and arms down by her side. The girl immediately begins to lean. What does this tell the nurse?

The child warrants further testing for cerebellar dysfunction. This indicates a positive Romberg test which warrants further testing for possible cerebellar dysfunction. Page 307

The nurse is examining the heart and peripheral perfusion of an 8-year-old. The nurse will assess the apical impulse at which location?

The fifth intercostal space lateral to the left midclavicular line The apical pulse can be found at the fifth intercostal space lateral to the left midclavicular line in children over 7 years of age. The apical pulse's point of maximal intensity is at the fourth intercostal space just medial to the child's left midclavicular line until age 4 years and at the fourth intercostal space at the left midclavicular line from ages 4 to 6 years. The fifth intercostal space medial to the left midclavicular line incorrectly locates the apical pulse medially rather than laterally for someone over 7 years. Page 301

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

The fourth intercostal space. The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. In children younger than 7 it occurs at the fourth intercostal space. page 301

What is typical of a grade II heart murmur?

The murmur is soft but easily heard. When assessing heart murmurs, a grading scale is used to describe the sound of the murmur. A grade II heart murmur is usually soft and it is easily auscultated. page 302

The nurse is performing an admission assessment on a 12-year-old who suffered a head injury in a motor vehicle accident. Which finding will alert the nurse that the client is demonstrating complications from the accident?

The nurse brings an ink pen toward and away from each eye and notes the pupil dilating as the object moves closer The eyes demonstrate accommodation, or focusing at different distances, if the pupil constricts as the object moves closer; dilating would indicate a possible neurological issue. Normal vital signs for a school-age child include a pulse of 60 to 100 bpm and a respiratory rate of 14 to 22 breaths per minute. Being able to rate pain shows intact neurological status. Cerumen lubricates and protects the external ear canal and is normally orangish-brown in color.

The nurse enters the hospital room of a toddler to perform an assessment. Which actions or statements by the nurse will impede the assessment process? Select all that apply.

The nurse removes the toddler's pajama shirt when assessing the blood pressure The nurse hugs the toddler to show care and nurturing when entering the room The nurse tells the parent that it is important for the child to lie on the bed rather than sit on their lap during the assessment Toddlers usually prefer to remove their clothing one item at a time as needed for the examination; only the arm should be removed from the pajama shirt for blood pressure measurement. The nurse should use little touch at the beginning of the encounter with the child and the caregiver; too much touch initially can scare the child. Toddlers will prefer to sit on the caregiver's lap during the assessment for security. pg 280

The nurse is weighing an 18-month-old infant 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. The toddler who is able to sit can be weighed while sitting. Keep a hand within 1 inch of the child at all times to be ready to protect the child from injury. Page 288

The student nurse is assessing a 9-year-old's cardiovascular system. Which assessment technique should the nurse further discuss with the student?

The student auscultates the heart at the third to fourth intercostal space just medial of the child's left midclavicular line. The point of maximum impulse (PMI) is lateral to the left midclavicular line at the fifth intercostal space in children ages 7 years and older. The student nurse is demonstrating auscultation of the PMI for a child under the age of 4 years. Page 301

The student nurse is performing an assessment of an infant. Which action by the student nurse requires further instruction by the instructor?

The student nurse asks the parents to step out of the room while performing the assessment It is often helpful for the parents to hold the infant during the assessment. This provides the infant with a sense of security during the assessment; therefore, it is not necessary for the parents to be asked to step out of the room during the assessment. Auscultation of the heart while the infant is sleeping allows a better assessment since the infant is not moving or crying. Assessing the ears often evokes crying so this should be left until the end of the assessment. Undressing the infant is necessary to perform a thorough assessment. Page 279

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 lesions described are consistent with strawberry nevus. They are benign and normally fade as the child ages, usually by the age of 9 years. Nevus flammeus are associated with the development of Sturge-Weber syndrome.

A 14-year-old male is brought to the clinic by his father with concerns that he is developing an excessive amount of breast tissue. The examination confirms that he has slight enlargement of the breast tissue. What information should be relayed to the teen and his parent?

This is a normal and transient condition of adolescent males. Breast growth in adolescent males may occur in response to hormonal levels. This condition will self resolve as hormones become more balanced. Therapy and laboratory studies are not indicated at this time. Page 299

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 Testing a child's hearing by observing a response to a whisper without a visual clue, assesses cranial nerve VIII, the acoustic nerve. Nerve V is the trigeminal, nerve IV is the trochlear, and nerve III is the oculomotor, none of which are involved in hearing. Page 295

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

Visible peristaltic waves Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age. Page 303

All infants should have their head circumference measured at health-assessment visits. This measurement is made from

just above the eyebrows through the prominent part of the occiput. Measuring heads consistently from above the eyebrows to the occiput allows measurements at different visits to be compared. Page 287

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

localized or generalized When assessing symptoms such as pain, rashes, or lesions, the location must be assessed for local or generalized. Pain should also be assessed for deep, superficial, or radiating. The other choices describe the quality and quantity of the symptom. Page 292