Peds Exam 2 Practice questions

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

"Auscultated all four quadrants for a full minute each" During assessment, the nurse should auscultate each quadrant for a full minute when assessing bowel sounds. Therefore, the nurse would include this statement in the teaching. The other statements are inaccurate. Hyperactive bowel sounds are often heard in clients with diarrhea. Bowel sounds should be present within a few hours of life. Bowel sounds are not generally audible with the naked ear.

The mother of a 2-month-old child reports her baby "breathes fast". When questioned further, the child's mother states she has counted the times using her watch and it was sometimes as high as 30 breaths in a minute. What is the best response by the nurse?

"Babies breathe rapidly and the amount you are reporting is within normal limits." Children of that age have a normal respiratory rate of 20 to 30 per minute. The child's reported respiratory rate is within that value. Although the respiratory rates for children can vary, this response does not fully answer the parent's question. Telling the parent not to worry does not address her concerns.

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?" RATIONALE: The most appropriate question to begin a health history is open-ended. This type of question allows the parent to elaborate on the health of the child. Close-ended questions such as asking if the child has been ill or if the child has been ill in the past limit the amount of information learned for the history. Expansive statements such as "tell me about your child" are too vague.

The nurse examines a 3-year-old girl in a health maintenance setting. What is the first question the nurse would ask her mother to obtain a health history?

"Do you have any concerns about your daughter?" RATIONALE: Beginning a health interview with an open-ended question about a chief concern opens up many topics for discussion.

The nurse is interviewing the parents of a 3-year-old child brought to the emergency department for fever and fussiness. Which question is the best example to use when completing a health history about pain?

"Does Sarah have pain?" RATIONALE: Open-ended and close-ended questions can both be effective when used during a health history. Close-ended questions ask directly for a fact and are limited in scope. They require no further explanation. Compound, expansive, and leading questions should be avoided. Compound questions elicit information that is often inaccurate and require follow up questions. Expansive questions are too vague to be answered. Leading questions supply their own answers.

A nursing student is learning about teaching and how to evaluate is effectiveness. Which of the following statements made by the student identifies a need for further instruction?

"Evaluation is done as a final step of teaching only."

When questioning a 15-year-old about his or her health history, what would be an appropriate way for the nurse to ask about the child's drug history? a) "Have you smoked crack before?" b) "Have you smoked cigarettes?" c) "Have you heard that some teens like to smoke? Have you tried this?" d) "Have you had alcohol at parties before?"

"Have you heard that some teens like to smoke? Have you tried this?" Correct Explanation: 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.

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 2 or 3 to help determine if growth is appropriate" Head circumference is typically assessed until age 2 or 3 years to help determine if growth is appropriate. This measurement is plotted on a growth chart to ensure head size is proportional to height/weight growth and to monitor for abnormalities, such as microcephaly or macrocephaly. The nurse will palpate to determine if skull suture lines have fused. The size of the infant's skull is not directly related to intelligence.

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 dolls 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.

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 makes which of the following statements? a) "I should establish good rapport with the child's parents before beginning an assessment on a child." b) "I should take a temperature using an electronic thermometer beginning at age 3 years." c) "I should take blood pressure on a child beginning at age 2 years." d) "I should take blood pressure on a child beginning at age 3 years."

"I should take blood pressure on a child beginning at age 2 years." Correct Explanation: 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 temperature on a child who is 3 years.

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 the blood pressure on a child at the beginning of 2 years" When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The recommendations are that blood pressure assessment be done at least once during every health care visit on children aged 3 years and older. Children younger than 3 years should have blood pressure assessed if they have a history of prematurity, have congenital heart defect, have a urinary tract infection, take any medications that influence the blood pressure or have increase intracranial pressure. Blood pressure measurement on hospitalized children is taken according to hospital policy no matter what age. 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.

The nurse is preparing a 5-year-old for a radiograph. What would be the best communication to prepare the child for the procedure?

"We are going to use a big camera to take pictures inside your body."

An adolescent who plays catcher on the baseball team begins shouting at the nurses, slams the doors, and refuses to talk to anyone after being given the news that the right arm will require surgery. Which response by the nurse would be the most appropriate in this situation?

"I understand you are angry, but please don't shout or slam doors."

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" The nurse should teach the child using terms a 6-year-old will understand. A chest x-ray is usually ordered for the assessment of asthma to check for hyperventilation. A sputum culture is indicated for pneumonia, cystic fibrosis, and tuberculosis; fluoroscopy is used to identify masses or abscesses as with pneumonia; and the sweat chloride test is indicated for cystic fibrosis.

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."

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 which statement?

"Intensity refers to how often the concern occurs during the day." Frequency refers to how often the concern occurs during the day. Intensity refers to the kind of problem. Associated symptoms are important to ask about.

A nurse is wrapping up a health interview with the father of a toddler. Which of the following would be the best question or statement to end the interview with? a) "Is there anything more about your daughter that we should know?" b) "Was yesterday a fairly typical day for your daughter?" c) "Before we talk about any past illnesses or happenings with your daughter, let me ask you some questions about your family as a whole." d) "I'd like to ask about different parts of your daughter's body, from her head down to her toes, just to be certain I don't miss anything."

"Is there anything more about your daughter that we should know?" Correct Explanation: A health history should close with one last open-ended question: "Is there anything more about your daughter we should know?" or "Is there anything I didn't mention you want to ask about?" A parent may have been reluctant to bring up something earlier. Asking this final question gives a parent a final opportunity to reveal a concern. The other questions should be asked in earlier sections of the health interview (day history, health and family profile, and review of systems).

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 build in the early 1900s" Homes or apartments built prior to 1978 may contain lead-based paint, and children who live there are at an increased risk for the development of lead poisoning. This paint may be exposed during a renovation so there should be further discussion on this topic. Being a "stay-at-home mom," babysitting by grandparents in a new condo, and a well-cared-for pet are not concerns that need to be investigated further.

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? a) "Please sit still so I can see inside your ears." b) "May I please look inside your ears?" c) "Come, sit on this pretty, little red chair." d) "Let's see if I can find some puppies or kittens."

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

Fourteen-year-old Freddy has come to his primary-care physician's office for a routine well-child visit. In reading the child's history, the nurse notes that Freddy's father suffers from alcoholism. If Freddy's mother makes the following statements, which statement would be most important for the nurse to gather further data regarding? a) "I think I know how Freddy feels about drinking. He has had substance abuse education in school." b) "Sometimes Freddy asks me questions about his father's low tolerance for alcohol." c) "Our next door neighbor is older than Freddy, and he drinks when they hang out together." d) "I wish there was a blood test for alcoholism. I know Freddy is at risk."

"Our next door neighbor is older than Freddy, and he drinks when they hang out together." Explanation: Some diseases and conditions are seen across families and are 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.

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." 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. A rectal temperature is usually 0.5° to 1.0° higher than the oral temperature and the axillary temperature is usually 0.5° to 1.0° lower than the oral temperature. It is easier to obtain a tympanic temperature in a sleeping child as the temperature can be obtained without walking them up.

The nurse is discussing taking a temperature on a child with a group of nursing students in a post-conference setting. Which of the following statements made by the nursing students is most accurate related to taking a temperature? a) "A rectal temperature is usually 0.5° to 1.0° lower than the oral measurement." b) "Tympanic temperatures should not be taken on a child who is sleeping." c) "Rectal temperatures should not be taken on a child with diarrhea." d) "An axillary temperature usually measures 0.5° to 1.0° higher than the oral measurement."

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

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 you 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.

Which statement is most appropriate when initiating a nursing action with a preschooler?

"These sticky snaps are for your chest."

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." Blueness of the hands and feet, known as acrocyanosis, is normal in newborns up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. This best response explains why the blueness is occurring without using medical terminology and lets the mother know this is expected and normal. The nurse should not dismiss the mother's concern or decide whether the mother should worry about her newborn.

The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?

"This is normal; her circulatory system will take a few days to adjust."

The nurse administers a Denver Developmental Screening Test to a preschooler. Which statement is the best introduction to this test for her mother?

"This test will identify different developmental skills your child can perform." RATIONALE: A Denver Developmental Screening Test (A Denver II) is well standardized. As its name implies, it measures development, not IQ. A parent is encouraged to watch.

Which statement by the nurse is most appropriate when discussing general anesthesia with a 6-year-old?

"This will be a very special sleep."

Which statement by the nurse encourages therapeutic communication from a child scheduled for surgery?

"What are you worried about?"

The nurse is performing a health history on a 6-year-old who is having trouble adjusting to school. Which question would most likely elicit valuable information?

"What are your new classmates like?"

The nurse is gathering data from the caregiver of 3-year-old Jared who was heard complaining that he was nauseated while sitting in the waiting room. In interviewing the child's caregiver, which of the following would be the most appropriate initial question for the nurse to ask the caregiver? a) "Does anyone else in the family have the same symptoms?" b) "Has Jared had anything to eat that he might be allergic to?" c) "What caused you to decide to bring Jared to the clinic today?" d) "How often does Jared complain of being nauseated?"

"What caused you to decide to bring Jared to the clinic today?" Correct Explanation: 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.

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.

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?"

A nurse is interviewing a father regarding his 2-year-old daughter's recent illness. The nurse would like the father to elaborate about any symptoms of the illness that he has noticed. Which of the following would be the most effective question for the nurse to ask the father in this situation? a) "Has your daughter exhibited any symptoms?" b) "Your daughter hasn't exhibited a fever, has she?" c) "What symptoms has your daughter exhibited?" d) "Has your daughter exhibited a fever and vomiting?"

"What symptoms has your daughter exhibited?" Correct Explanation: An open-ended question, such as, "What symptoms has your daughter exhibited?" allows a parent to elaborate, which is what the nurse desires in this case. A closed-ended question, such as, "Has your daughter exhibited any symptoms?" does not allow the parent to elaborate, and thus would be inappropriate in this case. Compound questions, such as, "Has your daughter exhibited a fever and vomiting?" should be avoided because the information they elicit is often inaccurate and must be clarified. Likewise, leading questions, such as, "Your daughter hasn't exhibited a fever, has she?" should be avoided.

The clinic nurse is interviewing a parent about the infant's illness and is in the chief concern part of the health interview. Which question will the nurse ask during this part of the interview?

"Why did you bring your infant to the clinic today? The chief concern deals with the reason the parent brought the child to the health care agency at this time. Asking "why did you bring your infant to the clinic today" addresses this concern. No other question addresses this concern.

The child with cancer spends time watching TV and talking very little about a new chemotherapy regime that is to start next week. What is the best statement the nurse could use to help the child discuss feelings about the new treatment?

"You haven't said anything about your feelings toward the new treatment plan."

The nurse is enlisting the parents' assistance for therapeutic hugging prior to an otoscopic examination. What should the nurse emphasize to the parents?

"You will need to keep his hands down and his head still."

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 RATIONALE: Blood pressure measurement begins to be a part of routine assessment at 3 years of age. The preschool E-chart is used for vision screening at this age. Walking gait and standing height measurement will be introduced in future assessments.

The nurse is identifying ways to support the 2020 National Health Goals during the upcoming preschool health screening program. What should the nurse include when conducting the program? Select all that apply:

* Conduct vision tests. * Conduct hearing tests. * Review immunizations received RATIONALE: To support the 2020 National Health Goals related to health assessment of children, the nurse should participate actively in health assessment, including vision and hearing, and screening for and administering vaccines. Listening to heart sounds and measuring gait and balance do not support the 2020 National Health Goals related to health assessment of children.

The nurse is preparing to conduct the cover test with a preschool-age child. Which body system is the nurse preparing to assess?

* Eyes RATIONALE: A screening procedure to determine eye alignment is the cover test. The cover test is not used to assess the ears, nose, or neck.

The nurse is preparing to assess a school-age child who is experiencing pain in the left femur area. When conducting this assessment, at which point should the nurse assess the painful region?

* Last RATIONALE: If a child has a sensitive or painful body part, palpate that area last. Otherwise, the child may be unwilling to allow other parts to be touched in fear of additional pain. The painful regions should not be assessed first, after measuring vital signs, or before the abdominal assessment.

When beginning a physical examination of a toddler, the nurse notes that the child has halitosis. On which body areas should the nurse focus when conducting the assessment? Select all that apply:

* Lungs * Oral cavity RATIONALE: Halitosis or bad breath is considered a significant body odor, which could be caused by poor dental hygiene, a lung infection, or a foreign body in respiratory tract. The nurse should focus the assessment on the lungs and the oral cavity. The urinary tract, reflexes, and abdomen will not help determine the cause for the patient's halitosis.

The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this client?

* Rhonchi RATIONALE: Rhonchi are snoring sounds that are made by air moving through mucus in the bronchi. This is a normal sound. Stridor is a crowing sound being made through a constricted larynx. This is an abnormal sound. Crackles are sounds made by air moving through fluid. This is an abnormal sound. Wheezing is a whistling sound made by air moving through a narrow bronchus. This is an abnormal sound.

The nurse is preparing to administer the Denver II Developmental Screening Test to a preschooler. Which areas of the child's development should the nurse explain to the mother that this test measures? Select all that apply:

*Social *Language *Fine motor *Gross motor skills RATIONALE: The Denver II Developmental Screening Test is the most widely used tool to assess early childhood development and rates the categories of personal-social, fine motor-adaptive, language, and gross motor skills. The nurse should explain to the parent before administering the test that this test does not measure intelligence but of the child's level of development or ability to perform age-appropriate tasks.

The nurse is caring for an infant involved in a motor vehicle accident. The nurse uses the modified coma scale for infants and notes the following: spontaneous eye opening, moaning to pain, and withdraws to pain. Which score will the nurse record?

10 The modified coma scale for infants may be used for infants instead of the Glasgow coma scale. The scale is broken down into eye opening, verbal response, and motor response. The infant's score is 10 based on these categories. The remaining answer choices are incorrect.

A nursing student learning pediatrics and the development of language correctly identifies the age when children are able to put together two-word (noun-verb) sentences to be:

2 years

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

24 months

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 which of the following? a) 3-day recall b) 12-hour recall c) 24-hour recall d) 1-week recall

24-hour recall Correct Explanation: 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.

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

3 years Blood pressure monitoring become part of the routine health exam at age 3.

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.

Which situation may be enhanced by the use of drawings to elicit feelings from a child?

A 4-year-old scheduled for surgery

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

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which of the following findings would warrant further investigation? a) Visible bony landmarks behind the membrane b) A gray tympanic membrane c) A mobile tympanic membrane d) A bubble behind the tympanic membrane e) A pearly pink membrane

A bubble behind the tympanic membrane Correct Explanation: 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 of the following findings should most warrant concern on the part of the nurse? a) A very dark mole with an uneven border b) A tattoo on the wrist, with no signs of inflammation c) A few acne lesions on the back d) A rash due to an allergic reaction to cosmetics

A very dark mole with an uneven border Correct Explanation: 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.

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

The nurse is preparing to measure the head circumference of a 6-month-old child. How should the nurse make this measurement?

Above the eyebrows through the prominent part of the occiput. RATIONALE: Head circumference is measured by placing a tape measure around an infant's head just above the eyebrows and around the most prominent portion of the back of the head or the occipital prominence. Head circumference is not measured using the hairline or the forehead.

Which of the following statements best explains the principle behind a Rinne test for determining hearing loss?

Air conduction of sound is normally better than bone conduction of sound. RATIONALE: Because air conduction of sound is better than bone conduction, a child will hear a tuning fork in front of the ear after he or she no longer hears it when placed against the bone behind the ear.

When assessing for bowel sounds, which statement is true?

All four quadrants should be auscultated in a consistent pattern. RATIONALE: Listening to all four quadrants reveals that bowel sounds are present throughout the intestine.

A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam?

Allow the child to play with the tuning fork.

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.

7) A mother who is bottlefeeding her newborn is discharged 48 hours postdelivery. When should the nurse schedule the first office visit for the newborn with the pediatrician? 1. Within 5 days of discharge 2. Within 7 days of discharge 3. Within 2 weeks of discharge 4. Within 3 weeks of discharge

Answer: 1 Explanation: 1. A newborn who is discharged from the hospital within 48 to 72 hours postdelivery should have the first office visit scheduled with the pediatrician within 5 days of discharge. 2. Newborns who are discharged within 48 to 72 hours postdelivery should be seen by the pediatrician before 7 days of age. 3. Newborns who are discharged within 48 to 72 hours postdelivery should be seen by the pediatrician before 2 weeks of age. 4. Newborns who are discharged within 48 to 72 hours postdelivery should be seen by the pediatrician before 3 weeks of age.

10) The nurse is teaching the parents of a toddler-age child about injury prevention. Which statement by the parent indicates the need for further education? 1. "I will turn the handles of the pots outward while I am cooking dinner." 2. "We will make sure that our child always wears a life vest when we are out in the boat." 3. "I will keep all our medications out of reach and ensure child-resistant containers." 4. "We will provide safe climbing toys for our child."

Answer: 1 Explanation: 1. Handles of the pots should be turned inward and not outward to prevent toddler injury. This statement indicates the need for further education. 2. A life vest should be worn by the toddler when near water or on a boat. This statement indicates correct understanding of the information presented. 3. All medications should be kept out of reach from the toddler and the parents should ensure child-resistant containers are used. This statement indicates correct understanding of the information presented. 4. Parents should supervise toddlers closely and provide safe climbing toys for the child. This statement indicates correct understanding of the information presented.

3) Which should the nurse keep in mind when providing care to an adolescent client during the initial visit? 1. The importance of explaining procedures and introducing personnel to adolescents. 2. Adolescents usually are quiet and will offer no opinions. 3. The importance of attending to and discharging the adolescent quickly. 4. Adolescents are comfortable with their surroundings.

Answer: 1 Explanation: 1. If the setting is new to the adolescent, explain the procedures and introduce personnel so the adolescent feels more at ease. 2. Adolescents usually will offer their opinions readily. 3. It is important that adolescents feel welcome, important, and unrushed in order to gain their trust. 4. When adolescents are visiting the same office or clinic that they came to during childhood, they usually know and feel comfortable with the healthcare providers. This is not the case if it is a first visit.

1) Which is the priority nursing action when performing a physical assessment on a toddler? 1. Leaving intrusive procedures such as eye and ear examinations until the end 2. Explaining each part of the examination to the child before performing it 3. Performing the assessment from head to toe 4. Asking the mother to tell the child not to be afraid

Answer: 1 Explanation: 1. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs. 2. A toddler is too young to understand the medical terminology. 3. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs. 4. Asking the mother to tell the child not to be afraid is an inappropriate response.

10) A mother reports that her adolescent daughter is always late. The mother states, "She was born late and has been late every day of her life." Which response by the nurse is appropriate? 1. "Setting specific alarms and then reinforce the value of being 'on-time' may be helpful strategies to assist her to be more of an 'on-time' individual." 2. "Just let it go for now. Teachers and, in the future, employers will be the best people to help her be 'on-time.'" 3. "You need to establish specific time frames for your adolescent and be certain she adheres to them." 4. "You have a major problem. There must be a lot of screaming in your home."

Answer: 1 Explanation: 1. The best response is to help the mother find a way to help the teen deal with the problem of lateness. 2. It is not appropriate for the nurse to advise the mother to do nothing. The parents are the ones responsible for changing their child's behavior. 3. The nurse who tells the mother to establish time frames is making the assumption this is not already the case in the household. 4. This answer choice makes assumptions about the household communication in which the parent and adolescent live.

5) A school nurse is performing annual height and weight screening. The nurse notes that three adolescent girls who are close friends each lost 15 pounds over the past year. Which is the priority nursing action? 1. Obtaining a nutritional history for each of these adolescents 2. Referring these adolescents to the school psychologist 3. Calling the respective parents to discuss the eating patterns of each adolescent 4. Speaking with the adolescents in a group to discuss the problems associated with anorexia nervosa

Answer: 1 Explanation: 1. The school nurse must evaluate why these three friends have all lost 15 pounds in 1 year. The best way to begin this assessment is to obtain a nutritional history for each client. 2. Referring the adolescents to a school psychologist without performing a complete nursing assessment is not appropriate. 3. Speaking with the parents would not be appropriate at this time. 4. Discussing anorexia nervosa at this point is too extreme.

12) The nurse is teaching the parents of a toddler-age child information regarding toy and playground safety. Which parental statement indicates the need for further education? 1. "I allow my child to play with the packaging material for new toys." 2. "I will avoid buying my child toys that are battery operated." 3. "I allow my child to play with age-appropriate toys as indicated on the packaging." 4. "I don't let my child play on the playground without supervision."

Answer: 1 Explanation: 1. The toddler-age child should not be allowed to play with packaging material for new toys as this increases the risk of injury. This statement indicates the need for further education. 2. The toddler-age child should not be allowed to play with battery-operated toys. This is not appropriate until the child is 8 years of age. This statement indicates appropriate understanding of the information presented. 3. The toddler-age child should be provided with toys that are age-appropriate. A parent who buys the child toys based on the age range on the packaging is appropriate and does not indicate the need for further education. 4. The toddler-age child should not be allowed to play on the playground without supervision. This statement indicates appropriate understanding of the information presented.

1) The nurse develops and implements a health promotion plan for an adolescent client. What should the nurse include in the evaluation of the plan? 1. Methods to expand and sustain successful approaches 2. Instruction to the client on what is considered healthy behavior 3. Advice for promoting health behaviors that will maintain a healthy lifestyle 4. Information on the client's attitude toward health

Answer: 1 Explanation: 1. When establishing youth programs, whether with individual adolescents or with groups, the nurse includes methods to expand and sustain successful approaches. 2. Instruction on healthy behaviors would be included in the implementation phase of the plan. 3. Advising why promoting healthy behaviors is important is part of the implementation phase of the plan. 4. Including the adolescent's attitude toward health has little to do with evaluating the success of the plan.

19) The nurse is preparing for a health maintenance visit for a 9-month-old infant. Which teaching topics are appropriate for the nurse to include during the scheduled visit? Select all that apply. 1. Using iron-fortified formula 2. Encouraging self-feeding of finger foods 3. Increasing the number of daily milk feedings 4. Encouraging cups for all feedings 5. Introducing burping techniques

Answer: 1, 2 Explanation: 1. The nurse should teach the parents the importance of continuing to use an iron-fortified formula until the infant reaches 12 months of age. 2. The nurse should encourage the parents to allow for self-feeding opportunities with finger foods. 3. The number of daily milk feedings should be decreased, not increased, at this stage of development. 4. While the cup should be introduced by 9 months of age, it is not appropriate for the nurse to encourage the use of a cup for all feedings until 12 months of age. 5. While it may be appropriate for the nurse to reinforce burping techniques through the first year of life, the nurse would not introduce this teaching at 9 months of age.

15) Which screenings are appropriate for an adolescent client who admits to being sexually active during a scheduled health maintenance visit? Select all that apply. 1. Herpes simplex virus 2. Gonorrhea 3. Chlamydia 4. Impetigo 5. Mononucleosis

Answer: 1, 2, 3 Explanation: 1. Herpes simplex 1 and 2 can be sexually transmitted and should be included in the screening. 2. Some individuals with gonorrhea may display no symptoms. Because it is a sexually transmitted infection, screening for it would be appropriate. 3. Chlamydia is the most common sexually transmitted infection in the United States. Screening is appropriate. 4. Impetigo is a skin infection caused by staphylococcus or streptococcus; it is not a sexually transmitted infection. 5. Although mononucleosis is sometimes called "the kissing disease," it is not considered a sexually transmitted infection. Sexual intercourse is not required for transmission.

16) Which topics are appropriate for the nurse to include when teaching preventive disease strategies during infancy? Select all that apply. 1. Metabolic screenings 2. Hearing screenings 3. Risks of environmental smoke exposure 4. Stranger danger strategies 5. Bike safety

Answer: 1, 2, 3 Explanation: 1. It is appropriate for the nurse to include information regarding metabolic screening when teaching preventative disease strategies to the parents of an infant. 2. It is appropriate for the nurse to include information regarding hearing screening when teaching preventative disease strategies to the parents of an infant. 3. It is appropriate for the nurse to include information on the risks of environmental smoke exposure when teaching preventative disease strategies to the parents of an infant. 4. Stranger danger strategies are more appropriate for the parents of a preschool-age child. 5. Bike safety is more appropriate for the parents of preschool-age and school-age children.

15) Which nursing actions are appropriate for the 2-month-old infant during a scheduled health maintenance visit? Select all that apply. 1. Reviewing infant fluid needs with the parents 2. Reinforcing the importance of heating bottles with water versus the microwave 3. Demonstrating proper gum care to the parents 4. Educating the parents to begin introducing solid foods, such as rice cereal 5. Recommending that juice be introduced in a sippy cup

Answer: 1, 2, 3 Explanation: 1. It is appropriate for the nurse to review infant fluid needs with the parents during the 2-month health maintenance visit. 2. It is appropriate for the nurse to reinforce the importance of heating bottles with water versus the microwave with the parents during the 2-month health maintenance visit. 3. It is appropriate for the nurse to demonstrate proper gum care to the parents during the 2-month health maintenance visit. 4. The nurse would not educate the parents to begin introducing solid foods during the 2-month visit. Solid foods are not introduced until 6 months of age. 5. While juice should only be offered in a sippy cup, the nurse would not recommend this during the 2-month health maintenance visit. This subject is appropriate during the 6-month health maintenance visit.

18) What is the purpose of making general observations during the assessment process for an infant during a scheduled health maintenance visit? Select all that apply. 1. To invite discussion with the parents 2. To validate positive parenting efforts 3. To promote a partnership between healthcare providers and parents 4. To decrease the risk of communicable diseases 5. To meet standards required for The Joint Commission accreditation

Answer: 1, 2, 3 Explanation: 1. One purpose for making general observations during the infant assessment process is to invite discussion with the parents. 2. One purpose for making general observations during the infant assessment process is to validate positive parenting efforts. 3. One purpose for making general observations during the infant assessment process is to promote a partnership between healthcare providers and parents. 4. Decreasing the risk for communicable diseases is not the purpose for making general observations during the assessment process for an infant. 5. Meeting The Joint Commission accreditation standards is not the purpose for making general observations during the assessment process for an infant.

17) Which assessment questions are appropriate when the nurse is assessing the mental health of a preschool-age client? Select all that apply. 1. "Is your child experiencing nightmares?" 2. "Does your child ask questions about the genitalia?" 3. "How do you implement punishment for your child when a rule is broken?" 4. "Is your child up-to-date on recommended immunizations?" 5. "Does your child wear safety equipment when riding a bicycle?"

Answer: 1, 2, 3 Explanation: 1. The nurse inquires about nightmares when assessing the mental health of a preschool-age client. 2. The nurse inquires about sexual exploration when assessing the mental health of a preschool-age client. 3. The nurse inquires about implementing punishment for broken rules when assessing the mental health of the preschool-age client. 4. Assessing immunization status is not included in a mental health assessment for a preschool-age client. 5. Assessing the use of safety equipment is not included in a mental health assessment for a preschool-age client.

17) Which actions are appropriate when the nurse is performing general observations during the assessment process for an infant? Select all that apply. 1. Asking the family how they are adjusting to having the infant in the home 2. Monitoring the parents for clinical manifestations associated with fatigue 3. Assessing for behaviors that indicate appropriate bonding 4. Placing the infant on the scale for a weight and length assessment 5. Auscultating heart and lung sounds while the infant is asleep

Answer: 1, 2, 3 Explanation: 1. When performing general observations during the assessment of an infant the nurse will ask the parents how they are adjusting to having an infant in the home. 2. When performing general observations during the assessment of an infant the nurse will monitor the parents for clinical manifestations associated with fatigue. 3. When performing general observations during the assessment of an infant the nurse will assess for behaviors that indicate appropriate bonding. 4. Placing the infant on the scale to measure height and weight is not an appropriate action when performing general observations during the assessment process. 5. Auscultating heart and lung sounds is not an appropriate action when performing general observations during the assessment process.

11) Parents are in the pediatric clinic with their infant for a 1-month checkup. Which assessment question regarding immunizations should the nurse ask the infant's parents? 1. "Did your baby receive the influenza vaccine prior to hospital discharge?" 2. "Did your baby receive the hepatitis B vaccine prior to hospital discharge?" 3. "Did your baby receive the rubella vaccine prior to hospital discharge?" 4. "Did your baby receive the rotavirus vaccine prior to hospital discharge?"

Answer: 2 Explanation: 1. The influenza vaccine is not administered at birth. 2. Hepatitis B is given routinely at birth. 3. The rubella vaccine is not administered at birth. 4.The rotavirus vaccine is not administered at birth

19) Which interventions will the nurse recommend for a toddler-age client who is biting other children at daycare? Select all that apply. 1. Using a time-out as a form of discipline for the child's behavior 2. Separating the child from the situation 3. Telling the child it is not okay to hurt another person 4. Inquiring whether the child is getting enough sleep 5. Implementing distraction to avert the behavior

Answer: 1, 2, 3, 4 Explanation: 1. A time-out is an appropriate intervention for the nurse to suggest when a toddler-age child is exhibiting behaviors that include other people, such as biting. 2. Separation of the child from the situation is an appropriate intervention for the nurse to suggest when a toddler-age child is exhibiting behaviors that include other people, such as biting. 3. It is appropriate to encourage the parents to tell the child that the behavior is unacceptable when the child is exhibiting behaviors that include other people, such as biting. 4. When a child is exhibiting behaviors that include other people, such as biting, it is appropriate to assess the amount of sleep the child is getting each night. Lack of sleep is a common cause for behaviors such as biting. 5. Distraction is appropriate for undesirable behaviors exhibited by the child; however this is not an appropriate when the child is exhibiting behaviors that include other people, such as biting.

18) Which nursing actions are appropriate when conducting a mental health assessment for a toddler-age child? Select all that apply. 1. Observing the child's interaction with family members 2. Asking the caregiver to describe the child's typical day 3. Giving the child a crayon to assess ability to use 4. Determining the number of hours the child sleeps each night 5. Inquiring about recent exposure to communicable diseases

Answer: 1, 2, 3, 4 Explanation: 1. When conducing a mental health assessment for a toddler-age child it is appropriate for the nurse to observe the child's interaction with family members. 2. When conducting a mental health assessment for a toddler-age child it is appropriate for the nurse to ask the caregiver to describe the child's typical day. 3. When conducting a mental health assessment for a toddler-age child it is appropriate to determine whether the child is mastering age-appropriate skills, such as the use of a crayon for a toddler-age child. 4. When conducting a mental health assessment for a toddler-age child it is appropriate to inquire about the number of hours of sleep the child gets each night. 5. The nurse assesses exposure to communicable diseases during a typical health maintenance visit; however, this action is not appropriate when assessing the toddler's mental health.

20) Which recommendations will the nurse make to the parents of a preschool-age child who is experiencing frequent nightmares? Select all that apply. 1. Reassure the child by back rubbing. 2. Repeat a nighttime routine, such a reading a story. 3. Bring the child to the parental bed. 4. Allow the child time to settle back into sleep. 5. Place a television in the child's room for distraction.

Answer: 1, 2, 4 Explanation: 1. It is appropriate for the parent to reassure the child by back rubbing when a nightmare occurs. 2. It is appropriate for the parent to repeat a nighttime ritual, such as reading a story. 3. It is not recommended for the parent to bring the child to the parental bed as the child may continue to awaken at night to continue this practice. 4. It is appropriate to allow the child time to settle back into sleep. 5. It is not recommended to place a television in the child's room as a form of distraction for the nightmare.

16) Which will the nurse assess in the family of a 3-year-old child during a pediatric clinic visit scheduled due to regressive behavior? Select all that apply. 1. Change in parental marital status 2. Level of education for each parent 3. Health of child's siblings 4. Maternal depression 5. Child's exposure to communicable diseases

Answer: 1, 3, 4 Explanation: 1. Changes that occur with the family members of a 3-year-old child could be the source of the regressive behavior being exhibited. It is appropriate for the nurse to assess for a change in parental marital status. 2. The nurse would not need to assess the level of education for each parent for a 3-year-old child exhibiting regressive behavior. This information will already be compiled in the child's medical record. 3. A change in the health of the child's siblings could cause regressive behavior. This is appropriate for the nurse to include in the family assessment. 4. Maternal depression can be associated with poor self-concept and could be a reason for regressive behavior. This is appropriate for the nurse to include in the family assessment. 5. While it is appropriate for the nurse to assess the child's exposure to communicable disease, this is not included in the family assessment for regressive behavior.

20) The nurse is educating the parents of a 2-month-old infant when to contact the healthcare provider. Which statements by the parents indicate the need for further instruction? Select all that apply. 1. "We will contact the doctor if our baby does not have a bowel movement each day." 2. "We will contact the doctor if our baby is vomiting." 3. "We will contact the doctor if our baby has a temperature greater than 99°F." 4. "We will contact the doctor if our baby does finish each bottle." 5. "We will contact the doctor if our baby develops a skin rash."

Answer: 1, 3, 4 Explanation: 1. Each infant will develop a pattern for bowel movements; some infants will have several each day, while others may have a bowel movement once every couple of days. This parental statement indicates the need for further education. 2. Infants are prone to dehydration; therefore, it is appropriate for the parents to contact the healthcare provider for vomiting. 3. Parents are instructed to contact the healthcare provider for a temperature greater than or equal to 99.3°F. This parental statement indicates the need for further education. 4. Failure to eat is a reason to contact the healthcare provider; however, failure to finish each bottle is not a reason to contract the healthcare provider. This parental statement indicates the need for further education. 5. A skin rash is a reason to contact the healthcare provider. This statement indicates appropriate understanding of the information presented.

14) Which nursing action is best when teaching adolescent health promotion and health maintenance topics? 1. Contacting the parents and asking what issues they have with their adolescents 2. Having the adolescents identify a personal health goal 3. Asking the advice of the counselors at school 4. Telling the adolescents information that will be included in the lecture

Answer: 2 Explanation: 1. Talking to the parents first is not necessary. Common issues that arise for adolescents should be discussed in general and not according to specific individuals. 2. Teaching topics will be directed at both health promotion and health maintenance. A good starting point is to have the adolescent identify a personal health goal, and begin teaching there. 3. It is not necessary for the nurse to ask the counselors at school for advice on health topics. 4. Lecturing an adolescent group is not as effective as having an honest and open discussion with adequate time for questions.

1) The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which of these strategies can be classified as health promotion and health maintenance? Select all that apply. 1. Instructing on how to use dental floss 2. Treating a child with a diagnosis of acute otitis media 3. Administering the flu vaccine to infants 6 to 23 months old 4. Working with new parents to create daily feeding schedules for infants 5. Conducting developmental screening examinations for toddlers

Answer: 1, 3, 4, 5 Explanation: 1. Administering flu vaccines, discussing feeding schedules, and instructing in oral health care are all health promotion and health maintenance topics. 2. Treating a child with an acute ear infection (otitis media) would not be a topic for health promotion or health maintenance because it is an acute illness. 3. Administering flu vaccines, discussing feeding schedules, and instructing adolescents in oral health care are all health promotion and health maintenance topics. 4. Administering flu vaccines, discussing feeding schedules, and instructing adolescents in oral health care are all health promotion and health maintenance topics. 5. Conducting developmental screening exams for toddler-age clients is an example of strategy that is classified as health promotion and maintenance.

9) A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the measurements 2 months ago were at the 25th percentile. Which interpretation of these data by the nurse is accurate? 1. The infant is not gaining enough weight. 2. The infant has gained a significant amount of weight. 3. These measurements most likely are inaccurate. 4. The previous measurements were most likely inaccurate.

Answer: 2 Explanation: 1. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. 2. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. 3. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight. 4. A comparison of these two sets of measurements shows that the infant has crossed 2 percentiles, going from the 25th to the 75th percentile, and has gained a significant amount of weight.

20) Which question is appropriate for the nurse to include in the assessment for an adolescent client related to[B1] developmental tasks? 1. "How are you adapting to the high school setting?" 2. "What type of relationship do you have with your friends? 3. "Have you thought about your future career goals?" 4. "Do you play any team sports?" [B1]Erin--edit OK?

Answer: 2 Explanation: 1. Adapting to high school is not the primary psychosocial developmental task of adolescence. 2. The primary task for the adolescent is to separate from parents and develop positive peer relationships. 3. Adolescents are considering various future occupations, but that is not their primary developmental task. 4. Although this is beneficial, it is not the developmental task of adolescence.

14) Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 4-year-old child? 1. Recognizing that food jags are common 2. Involving the child in snack selection and preparation 3. Encouraging the use of a highchair with a safety strap 4. Recommending the child consumes high-fat foods

Answer: 2 Explanation: 1. Food jags are not common for a 4-year-old child. This is more common for the 2-year-old child. 2. A 4-year-old child should be involved in snack selection and preparation. 3. The use of a highchair with a safety strap is not information that should be included for a 4-year-old child during a health maintenance visit. This is more appropriate for a toddler-age child. 4. Low-fat, not high-fat, foods should be encouraged during the health maintenance visit.

10) The mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. Which response by the nurse to the mother is appropriate? 1. "Let's ignore this behavior. It will stop sooner." 2. "What do you usually do or say during a temper tantrum?" 3. "This is definitely a temper tantrum. I know exactly what you are feeling right now." 4. "Pick up and cuddle your child now, please."

Answer: 2 Explanation: 1. Ignoring the behavior is not an effective way to problem solve for temper tantrums. 2. Asking the mother to describe her usual behavior via an open-ended question will encourage the mother to talk about home management and will lead the nurse to assist the mother in making a plan of care for temper tantrums. 3. Sympathizing with the mother may make the mother feel better at that moment but does not help the mother improve her child's behavior. 4. Cuddling the child will provide positive reinforcement to the child to continue that behavior. Providing a direct instruction to the mother in this manner is unlikely to elicit the mother's trust in the nurse.

13) The nurse is planning to teach a group of adolescents about what can happen when having unprotected sex. Which nursing action will allow effective communication with the group? 1. Offering personal opinions on the topic 2. Allowing for discussion among the participants 3. Lecturing on the topic for the allotted time without any discussion 4. Discussing sex education related to religious belief

Answer: 2 Explanation: 1. Personal opinions will not carry much weight with a group of adolescents. 2. Whatever the setting, the nurse partners with the adolescent, the parents, and other persons, such as teachers or school counselors, to plan appropriate goals and related interventions. Appropriate interventions include applying communication skills effective with teens, such as listening to concerns, allowing for discussion, and bringing peers who have had experiences related to the topic being discussed. 3. Lecturing without discussion will not draw in the adolescent to the content. 4. Discussing sex education from a religious viewpoint is not appropriate.

6) The nurse is working with first-time parents. Which activity will the nurse suggest to encourage the development of good muscle tone in their infant? 1. Placing the infant in an infant seat rather than lying down in a crib 2. Surrounding the infant with toys and other stimulating items to encourage motor movement 3. Swaddling the infant 4. Putting the infant to bed each night at 8 p.m., even if the infant protests with crying

Answer: 2 Explanation: 1. Placing the infant in an infant seat is more restrictive than lying in a crib, which allows free moment. 2. Encouraging movement best assists the infant to obtain good muscle tone. 3. Swaddling the infant, while calming for a young infant, restricts movement. 4. The bedtime has nothing to do with development of infant muscle tone.

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

6) The following information is collected during the nursing assessment: the adolescent's menses began when she was 12 years old; a current body mass index (BMI) of 27.5; inconsistent school performance over the last several years. Which is the priority area of teaching for this adolescent? 1. Menstrual cycle 2. Nutritional intake 3. School performance 4. Mental health status

Answer: 2 Explanation: 1. The menstrual cycle appears to have started at a normal time, and so it is not the priority. 2. The BMI for this client is too high, placing the adolescent at risk for cardiovascular disease, hypertension, and diabetes mellitus in later life. Therefore, nutritional intake is the most important topic to focus on with this client at this time. 3. School performance is important; however, this is not the priority. 4. Mental health status is important; however, this is not the priority.

7) The nurse is assessing an adolescent patient during a scheduled health maintenance visit. The adolescent's mother is currently in the examination room with the patient. Which topic should the nurse avoid until the mother has left the examination room? 1. School performance 2. Cigarette smoking 3. School friends 4. Seat belt use

Answer: 2 Explanation: 1. The nurse can ask general questions about seat belt use, academic performance, and school friends without breaching confidentiality. 2. The nurse must maintain the nurse-client relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. 3. The nurse can ask general questions about seat belt use, academic performance, and school friends without breaching confidentiality. 4. The nurse can ask general questions about seat belt use, academic performance, and school friends without breaching confidentiality.

2) The nurse is assessing an adolescent client to determine relationships with others. Which nursing action is appropriate? 1. Telling the parents that information from the assessment will be shared with them after the examination 2. Providing separate time to communicate with both the adolescent and the parents 3. Avoiding asking the parents their opinions of the adolescent's friends 4.Telling the parents they are not allowed to come into the examination room

Answer: 2 Explanation: 1. The nurse cannot share the information about the examination, as this is a breach of client confidentiality. 2. Provide time alone with both the adolescent and the parents so that everyone has time to talk freely and ask questions. 3. The nurse should include the parents' opinions of their child's friends. 4. The nurse cannot keep the parents out of the examination room, especially if the adolescent wants the parents there.

12) During a health maintenance visit an adolescent states, "I have no friends in my new school, and I no longer want to go to college. I know I will be lonely there, too." Which is the priority nursing action? 1. Stressing the importance of remaining in a close parent-child relationship during these stressful times 2. Promoting healthy mental health outcomes 3. Acknowledging the fact that it takes several months to make new friends at a new school due to adolescent exclusion behaviors 4. Helping the adolescent realize the value of postsecondary education

Answer: 2 Explanation: 1. The parent-child relationship should not be used as a substitute for the development of new peer relationships. 2. The adolescent is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental health outcomes for the child. 3. It would be more upsetting to the adolescent if the nurse made this comment. 4. It would not be appropriate to discuss the importance of a college education at this time because the adolescent must deal with the loss of friends and with developing new friends first.

4) During a scheduled health maintenance visit for a 6-month-old infant the nurse asks, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? 1. Health promotion 2. Developmental surveillance 3. Health maintenance 4. Disease surveillance

Answer: 2 Explanation: 1. While health promotion activities are related to developmental surveillance, this question is looking specifically at the milestones. 2. The question asked by the nurse is seeking information about developmental milestones; therefore, the nurse is involved in developmental surveillance. 3. While health maintenance activities are related to developmental surveillance, this question is looking specifically at the milestones. 4. These questions are not classified as disease surveillance questions.

12) A nurse is assessing an 11-month-old infant, and notes that the infant's height and weight are at the 5th percentile on the growth chart; the infant was previously plotted at the 25th percentile. Psychosocial history reveals that the parents are separated and are planning to divorce. Which is the priority when planning this infant's care? 1. Parental anxiety 2. Risk for failure to thrive 3. Excessive nutritional intake 4. Risk for injury

Answer: 2 Explanation: 1. While parental anxiety due to the situation may be occurring, this is not the priority when planning this infant's care. 2. This infant's growth curve indicates poor growth which places the infant at risk for failure to thrive. 3. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. 4. While the infant may be at a risk for injury, the priority is risk for failure to thrive.

2) The mother of a newborn asks the nurse what the purpose of the first scheduled health maintenance visit will be. Which are appropriate responses by the nurse to this question? Select all that apply. 1. "To determine if your baby is being abused." 2. "To determine compatibility between you and the provider." 3. "To discuss policies related to provision of care." 4. "To evaluate your understanding of the services offered." 5. "To determine your baby's risk for obesity."

Answer: 2, 3, 4 Explanation: 1. Only under very unusual circumstances would the healthcare providers be able to determine whether the parents are potential child abusers. 2. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and healthcare provider will get along well. 3. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and healthcare provider will get along well. 4. The initial visit should help to acquaint the parents to office policies and services offered by the office, and to determine whether the parents and healthcare provider will get along well. 5. Only under very unusual circumstances would the healthcare providers be able to determine whether the parents will tend to overfeed the infant and place the infant at risk for obesity.

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

Open-ended

19) Which teaching topics are appropriate for the nurse to include for an adolescent who admits to the use of chewing tobacco? Select all that apply. 1. Lung cancer 2. Nicotine addiction 3. Mouth cancers 4. Emphysema 5. Mouth ulcers

Answer: 2, 3, 5 Explanation: 1. Smokeless tobacco does not increase the risk of lung cancer. 2. Nicotine addiction occurs with chewing tobacco just as it does with smoking cigarettes. 3. Cancer of the mouth is associated with chewing tobacco. 4. Respiratory illnesses are not a common risk factor for smokeless tobacco. 5. Mouth ulcers occur in individuals who chew tobacco.

6) The parents of a 2-year-old girl inquire about information to help their child transition to bed each night. Which response by the nurse is appropriate? 1. Let the child cry self to sleep a few nights to adjust to the transition. 2. Play a favorite video at bedtime on a television in the child's room to enhance relaxation. 3. Read a book to the child just before bedtime each night. 4. Let the child fall asleep while playing and then put the child in bed.

Answer: 3 Explanation: 1. A child of this age will not just learn to fall asleep on her own if left alone. Letting the child cry for an extended period of time can affect attachment issues. 2. Having a television in a 2-year-old child's room is not a healthy practice. This can lead to decreased physical activity. 3. Developing a quiet routine just before bedtime can help calm the child and give an expectation to what will happen next: going to bed. 4. Letting the child fall asleep while playing is not healthy, as it allows the child to get to the point of exhaustion without any limits set.

9) An obese adolescent who adamantly denies sexual activity has a positive pregnancy test. Which response by the nurse is most appropriate? 1. "When was your last menstrual period (LMP)?" 2. "Tell me how you feel about your body image." 3. "Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy." 4. "Why are you denying sexual intercourse?"

Answer: 3 Explanation: 1. Asking about the LMP does not help connect the adolescent's past behavior to her pregnancy. 2. The adolescent's body image does not address the teen's current situation. 3. The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is to ask a direct question in which the nurse and client search for an answer. 4. This option is too confrontational and may alienate the adolescent.

14) The nurse is assessing a small-for-gestational-age newborn who had an older sibling who died of sudden infant death syndrome (SIDS). Which should the nurse include in the newborns plan of care based on these data? 1. Encourage the parents to sleep with the newborn for close observation. 2. Encourage the parents to place the newborn on the abdomen to sleep. 3. Encourage the parents to place the newborn in a crib with a tight-fitting, firm mattress. 4. Encourage the parents to place the newborn in a crib with a soft mattress with extra blankets.

Answer: 3 Explanation: 1. Cobedding is not encouraged because it is associated with an increased risk for SIDS. 2. A prone sleeping position is not encouraged because it is associated with an increased risk for SIDS. 3. Placing the infant in a crib with a tight-fitting, firm mattress will help keep the infant's mouth free of obstructions. This is the recommended sleeping position and environment for all newborns but is especially important due to the history of SIDS. 4. Quilts, blankets, and other soft items are not recommended as these increase the risk for SIDS. Put the newborn in a blanket sleeper instead.

13) Which observation in a health supervision visit leads the nurse to have concerns about the infant's mental health? 1. A 1-month-old is swaddled by the parent because of crying after an immunization. 2. A 7-month-old infant grabs her mother and cries when the nurse attempts touch. 3. A 9-month-old avoids eye contact with parents and the nurse. 4. A 10-month-old reportedly sleeps about 12 hours total per night.

Answer: 3 Explanation: 1. Crying after a painful procedure, such as an immunization, is a normal reaction by the 1-month-old infant. Swaddling the infant for comfort is a normal reaction by the parent. 2. Grabbing for her mother and crying when the nurse attempts touch is a normal reaction for a 7-month-old infant. 3. The nurse should expect the 9-month-old to have eye contact with the parents and the nurse. If no eye contact is made, the nurse should implement a more detailed assessment of the infant's mental health. 4. Sleeping 12 total hours per night is considered normal behavior for a 10-month-old infant.

4) Which action by the nurse is appropriate when teaching the parents of a 2-year-old child during a scheduled health maintenance visit? 1. Encouraging the parents to allow the child to pour liquids using a pitcher 2. Being sure that all major foods group have been introduced to the child 3. Teaching the parents that it is appropriate to switch from whole to 2% milk 4. Educating the child about food groups

Answer: 3 Explanation: 1. It is not appropriate to encourage the parents to allow the child to pour liquids using a pitcher until 3 years of age. 2. The nurse should ensure that all major foods groups have been introduced to the child at 1 year of age. 3. The nurse will teach the parents that it is appropriate to switch from whole to 2% milk during the 2-year-old's health maintenance visit. 4. The nurse would not educate the child about food groups until the age of 4 years.

8) Which parental statement during a scheduled health maintenance assessment for a preschool-age child would cause the nurse concern? 1. "We have dinner together as a family each evening." 2. "We are so proud that our child is able to recognize letters of the alphabet." 3. "Our child wakes up each night screaming because of nightmares." 4. "Our child attends a daycare program 3 days per week."

Answer: 3 Explanation: 1. Parents are encouraged to spend time with their children each day. The statement about eating dinner together each evening as a family would not cause the nurse concern. 2. A preschool-age child should be able to recognize letters of the alphabet. Parents who verbalize pride in their child would not cause the nurse concern. 3. A child who awakens each night due to nightmares may be indicative of a mental illness. This statement would cause the nurse concern. 4. Many children attend daycare due to both parents in the house working. The nurse should further assess the interactions between the parents and the caregivers; however, this statement would not cause the nurse concern.

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. RATIONALE: The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day. Day histories are fun to obtain because most parents are eager to describe their day with their child, and information gained this way is surprisingly rich and pertinent, much more so than if parents are just asked how their child sleeps, eats, or plays.

11) Which assessment finding for a toddler-age child indicates an increased risk for an unhealthy self-concept? 1. A parent who praises the child for his or her accomplishments 2. A parent who is attempting potty training but who understands that accidents will happen 3. A parent who is observed spanking a child for taking a toy from another child in the waiting room 4. A parent who reads a book to the toddler-age child each night before bed to encourage cooperation

Answer: 3 Explanation: 1. Praise from a parent to a toddler-age child for his or her accomplishments does not place the child at risk for an unhealthy self-concept. 2. A parent who attempts potty-training for a toddler-age child but expects accidents to happen does not place the child at risk for an unhealthy self-concept. 3. Physical discipline is a risk factor for the toddler to develop an unhealthy self-concept. 4. A parent who reads a book to a toddler-age child each night to encourage cooperation is not at risk for an unhealthy self-concept.

4) Which nursing action is appropriate when providing care to an adolescent client who is accompanied to an appointment by a parent? 1. Instructing the parent to stay in the waiting room with the explanation that the adolescent will provide a report after the examination 2. Telling the parent it is against policy for a parent to accompany the adolescent to the examination room 3. Reassuring the parent that the nurse will discuss any parental concerns or questions after the examination 4. Allowing the parent to come into the examination room with the adolescent

Answer: 3 Explanation: 1. The adolescent makes the decision about the parent's presence and whether to report the examination to the parent. 2. The adolescent decides when the parent comes into the room. 3. If one or both parents come with the adolescent, be alert that you might need to provide some private time by asking the parents to wait outside for a moment. Reassure the parents that you will talk with them about any of their concerns and questions, and provide them with an opportunity to ask questions and get information as well. 4. The adolescent chooses when the parent comes into the room.

8) The nurse is assessing an adolescent client during a scheduled health maintenance appointment. Which issues should the nurse address when the parents are not present? 1. The adolescent's role in the family 2. Teen job responsibilities 3. Possible domestic violence 4. Activities done as a family

Answer: 3 Explanation: 1. The adolescent's role in the family is not confidential and could be discussed when the parents are present. 2. Job responsibilities are not confidential and could be discussed in front of the parents. 3. If domestic violence is suspected, it would be appropriate to ask these questions only when the teenager is alone with the nurse or healthcare provider. 4. The activities of the family are not confidential and could be discussed when the parents are present.

9) Which immunization will the nurse provide parental education during the health maintenance visit for a 4-year-old child? 1. Hepatitis B #3 2. Haemophilus influenzae type B #2 3. Inactive poliovirus #3 4. Measles, mumps, and rubella #1

Answer: 3 Explanation: 1. The third hepatitis B vaccine is administered between 6 and 18 months of age. 2. The second Haemophilus influenzae type B vaccine is administered 6 months after the first vaccine, which is scheduled at 12 months of age. 3. The third inactive poliovirus vaccine is often administered between 4 and 6 years of age. The nurse would provide parental education during the health maintenance visit. 4. The first measles, mumps, and rubella vaccine is administered between 12 and 15 months of age.

16) Which nursing action maintains confidentiality when performing height and weight measurements during a co-ed physical education class? 1. Having a student worker record the screening findings on the appropriate adolescent's record 2. Having a volunteer weigh and measure the adolescents and verbally give the findings to the nurse to calculate the body mass index and record 3. Providing a privacy screen and have the health aid record the findings directly on the record. The nurse will then calculate body mass index 4. Using a buddy system with the students, having the students measure each other and record the findings.

Answer: 3 Explanation: 1. This would be inappropriate. Other students should not have access to any adolescent's private information. 2. Volunteers should not be included in the process of gathering data. Verbal reporting of findings would allow other adolescents to hear the results, violating the confidentiality of the student being screened. 3. A privacy screen and written responses will prevent other adolescents for hearing or seeing results. 4. Although this limits the number of adolescents who have access to personal data, this still is an invasion of privacy.

15) The nurse is conducting a physical assessment for a preschool-age child. When plotting the child's body mass index (BMI) the nurse notes that the child's is at the 90th percentile. Which action by the nurse is appropriate? 1. Referring the child to a nutritionist 2. Conducting a developmental assessment 3. Assessing the child's level of activity 4. Checking a blood glucose level

Answer: 3 Explanation: 1. While the nurse will need to assess a detailed dietary intake for the child it is not appropriate to refer the child to a nutritionist at this time. 2. There is no reason for the nurse to conduct a developmental assessment based on the current assessment data. 3. A child with a BMI that is 85% or greater should have a detailed dietary intake assessment conducted along with assessing the child's level of activity. 4. The current assessment data do not support the need to check the child's blood glucose level.

2) At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process? 1. 12 months 2. 18 months 3. 2 years 4. 4 years

Answer: 3 Explanation: 1. While the nurse will plot a child's growth at 12 months of age a BMI is not included in the physical assessment at this time. 2. While the nurse will plot the child's growth at 18 months of age, a BMI is not included in the physical assessment at this time. 3. BMI is first calculated at 2 years of age, and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that can reduce the incidence of obesity. 4. The nurse will not initiate BMI calculation for a 4 year old; this action should be implemented into the nursing assessment prior to 4 years of age.

A nurse is providing some basic hygiene teaching to a preschooler who is continually developing upper respiratory infections from his time spent in day care. What is an example of assessing the child's learning needs?

Asking him what germs are

18) The school nurse is assessing an adolescent who reports getting less than 6 hours of sleep at night. Which consequences of inadequate sleep will the nurse include when responding to the adolescent? Select all that apply. 1. Hyperactivity 2. Increased nocturnal emissions 3. Increased risk of automobile accidents when driving 4. Moodiness 5. An inability to perform well at school

Answer: 3, 4, 5 Explanation: 1. Inadequate sleep is more likely to lead to hypoactivity. 2. This is a common occurrence of early adolescence and not related to sleep deprivation. 3. This is a possibility in the adolescent who is sleep deprived. 4. Parents often report that sleep-deprived adolescents tend to be moody and are difficult to communicate with. 5. Drowsiness will inhibit the performance of the adolescent.

11) Which screening is appropriate for the school nurse to perform on all adolescent students? 1. Respiratory rate 2. Hepatitis B profile 3. Chest x-ray 4. Scoliosis

Answer: 4 Explanation: 1. A respiratory rate is not a screening examination for all adolescents. It is done throughout childhood at each health supervision visit. 2. The hepatitis B profile is needed only once, prior to administration of the hepatitis B vaccine; however, this is not a required screening for all adolescents. 3. A chest x-ray is not a routine screening test for adolescents. 4. Routine screening for adolescents includes checking for scoliosis, height, weight, and blood pressure measurements.

13) The nurse is planning health promotion activities for a toddler-age child during a scheduled health maintenance visit. Which action by the nurse is appropriate during this visit? 1. Connecting developmental skills with risks for injury 2. Recognizing that childcare attendance increases the risk for communicable disease 3. Planning education for treatment of common disease processes 4. Illustrating developmental progression on a screening tool

Answer: 4 Explanation: 1. Connecting developmental skills with risks for injury is an action that prevents disease and injury. This is not a health promotion activity. 2. Recognizing that attendance at a daycare center increases the risk for communicable disease is an action that prevents disease and injury. This is not a health promotion activity. 3. Planning treatment for common disease processes is an action that prevents disease and injury. This is not a health promotion activity. 4. Illustrating developmental progression on a screening tool is a health promotion action.

5) The visiting nurse is evaluating the home environments of several preschool-age children as they relate to child safety. The nurse visits the home of each child and gathers the following data. Which activity noted during the visit places a child at the greatest risk for bodily harm? 1. The parents are in a methadone program. 2. The parents consume alcohol on a daily basis. 3. The child watches television for 2 hours each day. 4. The child is permitted to swim in the family pool unsupervised.

Answer: 4 Explanation: 1. Drug and alcohol use or past use places the child at risk; however, this is not the priority risk assessed. 2. Drug and alcohol use or past use also place the child at risk; however, this is not the priority risk assessed. 3. A child who is allowed to watch excessive amounts of television each day is at risk for obesity and other health problems; however, this is not the priority risk assessed. 4. A child should be supervised while swimming at all times. This observation places the child at the greatest risk for bodily harm.

3) During a health supervision visit, the nurse is attempting to develop a partnering relationship with the child and family. Which is the initial action by the nurse? 1. Telling the family what the child should be doing physically for the age level 2. Telling the family that the healthcare provider will answer any questions they might have related to their child's growth and development 3. Setting goals for the family related to the child's health 4. Discussing a plan with the family to address the child's health needs

Answer: 4 Explanation: 1. Not all children develop each skill at the same age. Telling the family what the child should be doing can cause feelings of fear, frustration, and concern for the family if the child is not doing all of the activities listed by the nurse. 2. Telling the family to direct their questions just to the healthcare provider will not allow any teaching opportunities by the nurse, and will not allow for the development of a trusting relationship with the family. 3. The nurse should not set the goals without family involvement. 4. Discussing and developing a plan with the family will actively involve the family members and will build more trust, as they are not just being told what to do.

3) During a well-child visit with a 4-year-old girl the nurse notes that the parents speaks harshly to the child and used negative remarks when speaking with the nurse. Which statement by the nurse would be beneficial in this situation? 1. "Perhaps you should leave the room so that I can speak with your child privately." 2. "I am going to refer you for counseling since your interactions with your child seem so negative." 3. Addressing the child, the nurse says, "Are you unhappy when mommy talks to you like this?" 4. "Let's talk privately. We should discuss the way you speak with your child and possible ways to be more positive."

Answer: 4 Explanation: 1. Since the child is only 4 years old, it would be difficult to ask the parent to leave the room. If the nurse wants to speak alone with the child, it would be best to escort the child to another area and speak briefly with the child. 2. Referring to counseling without a discussion with the parent is not appropriate. 3. The nurse should not ask the child if she is "unhappy" with the parent. 4. The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation.

7) Parents of a preschool-age child report that they find it necessary to spank the child at least once a day. Which response by the nurse is appropriate based on this information? 1. "Can you try spanking the child only every other day for 1 week and see how that affects your child's behavior?" 2. "Spanking is one form of discipline; however, you want to be sure that you do not leave any marks on the child." 3. "I think you are not parenting properly, so let's talk about ways to improve your parenting skills." 4. "Let's talk about other forms of discipline that have a more positive effect on the child."

Answer: 4 Explanation: 1. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 2. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 3. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child. 4. The behavior reported by the parents was excessive. The only appropriate response is to seek a more positive way to influence behavior in a child of this age. The nurse's response must reflect these feelings and should address other forms of discipline that have a more positive effect on the child. To suggest that spanking is an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

8) While interviewing the parents of a toddler-age client, the nurse notes that the mother is pregnant. At the end of the visit, the nurse decides to give a new pamphlet to the parents about car seat usage for newborns. Which is the purpose of this action by the nurse? 1. Secondary preventative health maintenance 2. Developmental health screening 3. Tertiary preventative health maintenance 4. Primary preventative health maintenance

Answer: 4 Explanation: 1. The secondary level of prevention is focused on diagnosis of a problem, usually medical in nature, in order to address it and make a plan of care. 2. This is education, and not a developmental screening to elicit data. The focus of the teaching is on an unborn child, so developmental level is not a current issue. 3. The tertiary level of preventative care is related to restoring a level of functioning that is below an expected level, such as in a rehabilitation situation. 4. The teaching regarding proper car seat use is an example of an activity that might decrease the opportunity for injury in a newborn; therefore, this is primary preventive health maintenance.

17) The nurse is planning care for an overweight adolescent. Which topic may also be appropriate for the nurse to include in the adolescent's plan of care? 1. Substance abuse 2. School phobia 3. Spiritual distress 4. Negative self-esteem

Answer: 4 Explanation: 1. This is not the major mental health issue associated with obesity. 2. While the adolescent may dislike attending school, this is not the mental health problem the nurse should be evaluating. 3. Adolescents may have issues related to spirituality, but this is not associated with obesity. 4. Self-esteem is tied closely to body image, a common source of distress among obese adolescents. Therefore, the nurse will monitor the adolescent for issues with self-esteem.

5) A parent says to a nurse, "How do you know when my baby needs these screening tests the doctor just mentioned?" Which response by the nurse is most appropriate? 1. "Screening tests are done in the newborn nursery, and from these results, additional screening tests are ordered throughout the first 2 years of life." 2. "Screening tests are done at each office visit." 3. "Screening tests are most often done when the doctor suspects something is wrong with the child." 4. "Screening tests are administered at the ages when a child is most likely to develop a condition."

Answer: 4 Explanation: 1. This provides incorrect information to the parent. Abnormal newborn screening tests require immediate follow-up. 2. This provides incorrect information to the parent. Screening tests are not done at each office visit. 3. This provides incorrect information to the parent. Screening tests are done to detect the possibility of problems, and are not done when a problem is suspected. 4. "Screening tests are administered at ages when a child is most likely to develop a condition" provides a definition for screening tests.

When caring for hospitalized teens, nurses should choose their words and actions carefully since adolescents typically are concerned about:

Appearing out of control of the situation and/or themselves

When 12-year-old Chelsie comes in for her annual check-up, the nurse must take a health history and do a physical exam. What is the most appropriate manner for the nurse to obtain a health history? a) Ask Chelsie to fill out the health form and return it herself. b) Ask Chelsie if she minds if her mother is in the room with her. c) Ask Chelsie to wait outside while the nurse talks with her mother. d) Ask Chelsie's mom to leave the room.

Ask Chelsie if she minds if her mother is in the room with her. Correct Explanation: Cultural and spiritual dynamics are important in taking a health history. This age of child likes choices and is concerned about modesty and privacy. For pre-adolescents, letting children choose whether or not a parent is with them in the exam room and during the history is appropriate. In either event, it is important to speak with the adolescent alone at some point. Asking Chelsie to wait outside does not acknowledge her as a person. Asking Chelsie's mom to leave the room does not give Chelsie a choice in her care. Asking Chelsie to fill the form out herself is not supportive, and does not facilitate an exploration of her history.

The nurse is examining the testicles of a 6-year-old boy. How can the nurse prevent a retractile testis from slipping back up the inguinal canal? a) Ask the boy to stand. b) Ask the boy to sit cross-legged. c) Apply gentle pressure on the inguinal canal. d) Place one finger over the inguinal canal.

Ask the boy to sit cross-legged. Correct Explanation: For a 6-year-old boy, sitting cross-legged reduces the cremasteric reflex that retracts the testicles during palpation. Having a boy stand is best for an adolescent. Placing a finger over the inguinal canal or applying gentle pressure would be best for an infant.

The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. Which of the following is the most appropriate way to gather information from the child's caregiver? a) Ask the caregiver if they can read or if they need someone to read the questions on the admission form to them. b) Ask the caregiver questions and write the answers down. c) Have the caregiver sit in a quiet room and fill out a questionnaire. d) Have the child read the questions to the caregiver and then write down the answers on the form.

Ask the caregiver questions and write the answers down. Correct Explanation: 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. (less)

The nurse seeks to know how much time a preschooler's parents spend playing with the child every day. Which is the best way to obtain this kind of information?

Ask the parents for a day history. RATIONALE: A day history ("walking" through the child's day) reveals how much time is actually spent in play.

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

Five to 10 per minute RATIONALE: The usual frequency of bowel sounds is 5 to 10 per minute.

Why does the nurse complete a process recording?

For self-evaluation of therapeutic communication

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 caring for a child who appears fearful and is reluctant to talk. The nurse uses therapeutic communication skills to interact with the child. What initial goal does the nurse accomplish when using these skills to communicate with the child?

Assess the perception of the problem.

The nurse preceptor observes a novice nurse perform a pediatric assessment. Which action by the novice nurse will the nurse preceptor determine is a normal variance to assessment technique when compared to the assessment of an adult patient?

Assessing the abdomen before assessing the head and neck

What should be the first step in developing a teaching plan for a 9-year-old who needs education about a gluten-free diet for the treatment of celiac disease?

Assessing the child's current level of understanding

The nurse is preparing care for a preschool-age child scheduled for a health history and physical assessment. At which point will the nurse determine a nursing diagnosis that is appropriate for the child's care?

At the time of assessment RATIONALE: Nursing diagnosis related to health assessment most commonly address a health concern identified at the time of the assessment. When establishing nursing diagnoses, do not overlook diagnoses that accentuate the healthy functioning of a child and family, even when diagnoses that address specific problems have been identified. Wellness diagnoses are crucial components of the entire assessment picture. The nurse cannot identify diagnoses before the assessment occurs.

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

Axillary temperature, femoral pulse, head circumference

A nurse is performing a physical examination on a newborn. Which of the following assessments should she include? a) Temporal temperature, blood pressure, reflexes b) Oral temperature, blood pressure, head circumference c) Axillary temperature, femoral pulse, head circumference d) Rectal temperature, femoral pulse, head circumference

Axillary temperature, femoral pulse, head circumference Correct Explanation: 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.

A nurse is caring for a 10 year old with asthma. The child states, "I hate school because I am always sick. Nobody will ever choose me to be on their team." What level of communication is the child displaying?

Fourth Level: Shared Feelings

A nurse is demonstrating dressing changes for a 12 year old so that the child will be able to perform the skill when discharged. What is important for the nurse to do prior to demonstration?

Be sure that all necessary equipment is present to demonstrate the technique.

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 taking an apical pulse on an infant. The nurse should place the stethoscope at which of the following sites? a) Above the clavicle on the left side b) Between the sternum and the left nipple c) Above the sternum, slightly to the right d) Below the ribs about one half of an inch

Between the sternum and the left nipple Correct Explanation: When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum.

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

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

Which of the following assessments would you expect to introduce for the first time in the physical examination of a 3-year-old child? a) Observation of walking gait b) Blood-pressure recording c) Snellen vision testing d) Standing height measurement

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

The nurse notes that a school-age child does not participate in any teaching or demonstrate any learning identified in the plan of care as priority problems. What action should the nurse implement?

Change the plan of care to include the problem that is more consistent with the child's priority problems.

The nurse is teaching the parents how to provide enteral feedings to their child. Place in order the steps the nurse would teach the parents to accomplish this task. Use all options.

Check for correct tube placement Set the pump rate Wash hands Check for residual Fill the feeding bag Begin feeding

The nurse is interviewing the mother of a child who is at the local clinic. When asked why she brought her toddler in today, she replies that he has been running a fever and coughing a lot since last weekend. This information would be noted in the chart as what data?

Chief complaint

While interviewing a mother about her infant son's illness, the nurse asks, "Why did you bring Clark to the clinic today, Ms. Donovan?" Which part of the health interview is this nurse currently in? a) Day history b) Chief concern/complaint c) Demographic data d) Health and family profile

Chief concern/complaint Correct Explanation: The first topic parents want to talk about is the reason they have brought the child to the health care agency on the day, or the chief concern/complaint. An effective way to elicit this information is to ask directly, "Why did you bring Clark to the clinic today, Ms. Donovan?" Demographic data refers to data such as a child's name, address, gender, social security number, and the name of the person who will be providing information. A family profile includes documentation of the circumstances in which the child lives. The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day (day history).

During a previous well-child visit, the nurse reviews the importance of immunizations for the preschool-age child with the parents. Which outcome indicates that the nurse's instruction to the parents has been effective?

Child has all immunizations up to date. RATIONALE: One of the most important health assessment and promotion measures for children is to establish their immunization status is up to date. The nurse should teach parents about the importance of having their children immunized and the need to be able to describe the record of immunizations a child has received. If gaps are present in a child's number of immunizations, remind the child's primary care provider about this lack in protection and prepare to administer the necessary vaccines. The child's immunizations begin up to date indicate that the nurse's instruction has been effective. Having the child immunize within a year might expose the child to pathogens than could be avoided. Children will cry when receiving injections. This is not a valid reason to postpone immunization. The health care provider needs to understand the importance of childhood immunizations to be received at the correct age and time.

A 6-year-old reports pain in the stomach upon eating. The nurse replies, "Let me see if I have this right. Every time you eat anything, you get a pain in your tummy?" The nurse is using which technique of therapeutic communication?

Clarifying

A nurse is talking with a 10 year old who is saying that his "stomach has been hurting for several days and is worse when he drinks milk." The nurse asks the child, "Let me be sure I understand. The pain gets worse when you drink milk?" What type of therapeutic communication technique is the nurse using?

Clarifying

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

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? a) Open anterior fontanel and closed posterior fontanel b) Closed anterior fontanel and open posterior fontanel c) Closed anterior and posterior fontanels d) Open anterior and posterior fontanels

Closed anterior and posterior fontanels Correct Explanation: 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.

A nurse is teaching a young patient about the importance of good nutrition for wound healing. When the patient states, "I will eat more protein and take my vitamins so I will get better faster," this patient is demonstrating which type of learning?

Cognitive

A nurse is showing a 9 year old a video about why insulin is needed. The nurse then plans to discuss a booklet with the child on the same topic after the video. Of what type of learning is this an example?

Cognitive learning

The nurse is caring for a child who is on a cardiac monitor. Which of the following nursing actions would be the most important action for the nurse? a) Clean the skin with alcohol before placing the electrodes. b) Check to be sure that the electrodes are secure when the alarm sounds. c) Confirm the alarms are set with maximum and minimum settings. d) Check the site and skin condition every couple of hours.

Confirm the alarms are set with maximum and minimum settings. Correct Explanation: Cardiac monitors are used to detect changes in cardiac function. The highest priority would be to ensure the alarms are set with maximum and minimum settings and that the alarm is turned on. Many of these monitors have a visual display of the cardiac actions. Electrodes must be placed properly to obtain accurate readings of the cardiac system. The skin is cleaned to remove dirt, lotions, and powder before the electrodes are applied. The electrode sites must be checked every two hours to detect any skin redness or irritation and to determine that the electrodes are secure.

The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam?

Convey the impression that there are no right or wrong answers

The nurse is conducting the Denver articulation screening examination (DASE) with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam? a) Have the child read each of the 22 words from a sheet of paper b) Convey the impression that there are no right or wrong answers c) Modify the directions of the test using the nurse's own discretion d) At the end explain which words the child missed and why

Convey the impression that there are no right or wrong answers Correct Explanation: The DASE is designed to detect significant developmental delays as well as normal variations in the acquisition of speech sounds. Because it is a standardized test, its directions must be followed precisely, not modified according to the nurse's own discretion. Before the test, explain the child will need to repeat the words she hears you speak. Give enough examples you are certain she understands what she is to do: "When I say 'boat,' then you say 'boat.'" When you are certain the child understands the directions, say each of the 22 words shown on the DASE form; do not have the child read the words from a sheet of paper. Convey the impression that there are no right or wrong answers. Give the child approval for responding and following directions correctly, no matter how inaccurately the child repeats the word; the nurse should not explain which words the child missed and why.

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? a) Count the respiratory rate for 30 seconds. b) Place a stethoscope to count respirations. c) Count abdominal movements. d) Count after the child stops crying and is comfortable.

Count after the child stops crying and is comfortable. Correct Explanation: 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.

The nurse prepares to perform a head-to-toe exam on an infant. Which nursing action will the nurse perform?

Count the infant's respirations for a full minute

The nurse is assessing eye alignment in a 6-year-old. Which assessment method is most appropriate?

Covering one eye and then removing the cover. RATIONALE: A "cover test" allows a deviated eye to wander while covered and straighten when uncovered. Eye tests require the child to stare at a distant mark. Neurological tests have the child touch the finger to the nurse. Bright lights, directed at the eyes, test pupil response.

While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as what grade?

Grade 2

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 is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first? a) Family profile b) Details about the fever c) Review of systems d) History of past illnesses

Details about the fever Correct Explanation: 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.

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 RATIONALE: 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.

The pediatric nurse is caring for an 8-month-old infant and notes that the infant sucks half-heartedly while drinking a bottle of formula. Which action by the nurse takes priority?

Determine if this is a change from a previous behavior

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.

An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first?

Determine the type of ingestion Utilizing the sense of smell during a health assessment helps the nurse to focus on finding a source for the odor and the potential cause of the odor. When the smell of camphor is present the nurse should evaluate for the ingestion of mothballs. Urine that smells like maple syrup is a symptom of a protein metabolic condition. A sweet smell is associated with a pseudomonas infection. A putrid smell can be associated with fat in the stool from inadequate absorption. Prior to initiating any treatment it is important to find what the child has ingested if at all possible. The poison control center can provide antidotes and treatment protocols for all types of ingestion. The nasogastric tube and/or activated charcoal may or not be needed depending on the type of ingestion that has occurred.

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 should the nurse do next?

Document the findings as normal With inspiration and the resulting increase or pressure in the lungs, the pulmonary valves close slightly later than the aortic valve. This causes a variation in heart sounds. This is termed physiologic splitting and is heard as a "lub d-dub" sound. As long as this is associated with inspiration this is a normal finding. If splitting were to be consistently heard this would indicate difficulty with the pulmonary valve closing and suggests pathology. Because this is a normal finding no referrals need to be made.

A nurse caring for a preschooler scheduled for abdominal surgery the next day needs to teach about the dressing and drainage tube that the child will have after surgery. Which would be the best technique for the nurse to use?

Dolls and puppets

While caring for a child recovering from viral pneumonia, the nurse examines his lungs for evidence of exudate and fluid. Which finding would suggest cause for concern?

Dullness of his lower lobes heard on percussion. RATIONALE: Dullness of lower lungs suggests they are filled with fluid and not aerating fully.

A 5-year-old girl tenses up when the nurse approaches to examine her. "Are you afraid?" the nurse asks her. The girl shakes her head in denial. As the nurse lifts the stethoscope to auscultate the girl's chest, however, the nurse notices that the girl tenses up again and grips the edge of the examination table tightly. "Oh—you are afraid of the stethoscope, aren't you?" the nurse replies. "It's okay—it doesn't hurt; see—reach out and touch it." Which communication technique is the nurse demonstrating here?

Empathy

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.

Which example shows the nurse incorporating informal teaching while caring for a child?

Explaining the importance of adequate fluid intake while playing "tea party"

The nurse is using nonverbal communication techniques including the appropriate use of distance. Which situation best demonstrates the appropriate action by the nurse?

Explaining the use of the stethoscope before entering the intimate space of a 16-year-old

Infants learn best by affective learning.

False

A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding?

Fanning of the infant's toes

Anna is 4 years old and complains of ear pain. To examine Anna's ear, how should the nurse proceed? a) Grasp the pinna and pull down and back. b) Grasp the pinna and pull forward. c) Grasp the pinna and look inside. d) Grasp the pinna and pull up and back.

Grasp the pinna and pull up and back. Correct Explanation: 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.

A nurse is conducting a physical examination on a 5-year-old boy and is examining his abdomen. First she visually inspects the region. Then she auscultates it with a stethoscope. Finally, she palpates the area. What is the proper rationale for performing the auscultation before palpation? a) Handling the abdomen may obliterate bowel sounds b) The order does not matter; she could have performed palpation before auscultation c) If she detects no abnormalities in auscultation, there will be no need for palpation d) Auscultation is scary for small children and should thus be performed first, to get it over with

Handling the abdomen may obliterate bowel sounds Correct Explanation: Unlike in other regions, in the abdomen auscultation should follow inspection and precede palpation of the abdomen because handling the abdomen may obliterate bowel sounds. Not detecting abnormalities on auscultation does not eliminate the need for palpation. Auscultation is not necessarily scary for small children.

The mother tells the nurse her daughter has come to the clinic today because she has been having stomach pain. What should the nurse ask the mother? Select all that apply.

Has the child had fever? Where is the pain located? How long has she had pain? When was the last bowel movement? Have you given her any medication for the pain?

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.

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

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?

When assisting with the physical exam of a 1-year-old child, the nurse notes the following findings. Which finding would be concerning to the nurse?

Heart rate of 80

The nurse is taking a family history of a 10-year-old with asthma. What would be a helpful tool to obtain a family history of illness and disease? a) Have the family write down any history they remember. b) Have the family fill out a health questionnaire. c) Make a family tree for tracking purposes. d) Help the family design a genogram.

Help the family design a genogram. Correct Explanation: A genogram diagram shows the relationship between family illnesses and diseases in a visual manner. The other choices put the history responsibility on the patient and family and do not show a relationship among illnesses.

What is the most positive benefit that effective therapeutic communication has in the nurse-client relationship?

Helps develop trust between nurse and the child.

The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason?

Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems.

Which of the following should a nurse include in her pediatric history of 8-year-old patient Rosie? a) How many friends Rosie has b) Where Rosie lives c) Immunizations d) Her favorite toys

Immunizations Correct Explanation: Immunizations should be included in a pediatric history. This tells whether Rosie is up to date according to standard recommendations. This also shows the health promotion that Rosie is involved in. The other choices are part of Rosie's life but not critical factors.

Nurse Betty is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? a) In the nurse's own arms b) In the child treatment room c) In the crib facing the mom d) In the crib on the infant's back

In the crib facing the mom Explanation: When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view.

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statement accurately describes a recommended guideline for setting the tone of the examination for a school-age child?

Include the child in all parts of the examination; speak to the caregiver before and after the examination.

A 4-year-old is scheduled for major abdominal surgery. Which teaching should the nurse provide regarding pain?

Information on expected pain and ways to allieviate pain

Which technique would you begin with to assess a child's abdomen? a) Percussion b) Inspection c) Auscultation d) Palpation

Inspection Correct Explanation: Inspection is typically the first assessment technique used.

Which technique would you begin with to assess a child's abdomen?

Inspection RATIONALE: Inspection is typically the first assessment technique used.

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

Inspection RATIONALE: To assess an abdomen, first inspect the surface for symmetry and contour. After inspection, the nurse should auscultate for bowel sounds. The examination concludes with percussion and palpation.

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

Below are the first six (of nine total) sections of an initial health assessment interview. Put them in the correct order: Introduction and explanation History of chief concern/complaint Chief concern/complaint Demographic data Day history Health and family profile

Introduction and explanation Demographic data Chief concern/complaint History of chief concern/complaint Health and family profile Day history Correct Explanation: Data gathering for an initial health assessment can be divided into nine sections in the following order: 1) introduction and explanation; 2) demographic data; 3) chief concern; 4) history of chief concern; 5) health and family profile; 6) day history; 7) past health history, including pregnancy history; 8) family health history; 9) review of systems.

Which element is a characteristic of therapeutic communication?

Is constructive

Nurse Julie is doing a physical exam on a 3-year-old boy. What method would Julie use to perform the exam? a) Julie would examine the child's extremities first and then the chest. b) Julie would examine the child's chest and then go to the head and down. c) Julie would examine the child's head and work down to the child's toes. d) Julie would examine different sections of the body at various times.

Julie would examine the child's head and work down to the child's toes. Correct Explanation: 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.

When performing a lower extremity assessment which manifestation would be most important for the nurse to evaluate further?

Limping

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 Moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs. This response should not persist after 4 months of age. The Babinski reflex is tested through stimulating the foot/toes. The palmar reflex is tested through the hand/fingers. The root reflex is tested through touch on the corner of the mouth.

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 for? a) Startle b) Moro c) Palmar grasp d) Babinski

Moro Correct Explanation: The moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs. This response should not persist after 4 months of age. The Babinski reflex is tested through stimulating the foot/toes, the palmar reflex through the hand/fingers, and the startle reflex through loud noises (e.g., clapping).

The nurse has given an adolescent a pamphlet about sexually transmitted infections (STIs). Which documentation by the nurse shows that the teaching has been effective?

Named two methods used to reduce the risk of STIs

A nurse is talking with a 9-year-old about a procedure that will be done in the morning. The child is expressing fear. What listening skills does the nurse exhibit that makes it clear the nurse is actively listening? Select all that apply.

Nodding in response to comments the child makes Sitting at the level of the child Maintaining eye contact while the child is talking

A full term gestation infant weighed 8 pounds 1 ounce (3.7 kg) at birth. The baby's weight at the 4-month-old well-child visit is 10 pounds 2 ounces (5 kg). Which intervention should the nurse implement first?

Notify the healthcare provider of the findings.

The nurse should instruct the pregnant client not to receive which vaccine?

Oral polio

After eliciting a chief concern from a client, a nurse continues gathering information about related and other health concerns. Why is it important for the nurse to ask a second time at the end of the interview if there are other concerns?

Parents will not always reveal their most important concern in the initial minutes of the interview.

A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth?

Pinpoint ulcers on the gums

The nurse is measuring the head circumference of a child. Which of the following is accurate related to this procedure? a) Place the tape measure around the head just above the eyebrows. b) Place the tape measure around the head with the tape touching just below the eyes. c) Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. d) Measure the head circumference routinely on children up to the age of 6 years.

Place the tape measure around the head just above the eyebrows. Correct Explanation: 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.

A 9-year-old with rheumatoid arthritis has difficulty moving her painful hands as well as her other joints. She refuses to participate in ordered physical therapy. What would be the best way for the nurse to make sure she continues to exercise her joints?

Play a game like "Simon Says" to introduce exercises.

The nurse is assessing the growth of a premature infant. What would be the appropriate action by the nurse to complete this assessment? a) Take vital signs. b) Weigh the infant's diapers. c) Plot the infant's weight, height, and length on a growth chart. d) Ask mom if her baby eats enough.

Plot the infant's weight, height, and length on a growth chart. Correct Explanation: 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.

The pediatric nurse is caring for a group of children of various ages. When assessing the children's blood pressures (BP), which child's reading should be reported to the health care provider? Select all that apply.

Preschooler with BP 70/42 mmHg Adolescent with BP 142/90 mmHg

A nursing instructor informs a student to record her interaction with a child who has osteogenesis imperfecta to determine if the conversation was therapeutic. What form of evaluation is this?

Process recording

A 6-year-old child is learning how to draw insulin into a syringe and becomes frustrated, throwing himself on the floor. What is the best action by the nurse?

Provide positive reinforcement for the steps achieved, ignoring the temper tantrum

An 8-year-old is scheduled to have a tonsillectomy and adenoidectomy in 2 weeks. What intervention can the nurse provide to help the child and family adjust to the hospitalization?

Take the child on a tour of the facility and surgical suite and explain what to expect preoperatively and postoperatively.

A nursing student asks the nursing instructor to explain pulse oximetry measurements in child. The nurse is accurate in telling the student which of the following? a) Pulse oximetry measures the oxygen saturation of arterial hemoglobin. b) If the oximeter probe is to be left in place, the site should be checked every eight hours. c) Pulse oximetry is done to detect respiratory retractions in the child. d) Place the probe of the oximeter on the child's chest and secure it with tape.

Pulse oximetry measures the oxygen saturation of arterial hemoglobin. Correct Explanation: Pulse oximetry measures the oxygen saturation of arterial hemoglobin. The probe of the oximetry unit can be placed on the finger, toe, or clipped on the earlobe. In an infant, the foot or toe is often used. In certain situations the probe is left in place to continually monitor the oxygen saturation. Check the site every two hours to ensure that the probe is secure and tissue perfusion is adequate. Change the site at least every four hours to prevent skin irritation.

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 nurse is performing an examination of the eyes of a 7-year-old girl. Which of the following findings would indicate that the third cranial nerve is intact? a) Pupil constriction in response to light b) Light of an otoscope reflecting evenly off both pupils c) Pupil dilation in response to light d) The eyelid blinks in response to touching the cornea with a wisp of cotton

Pupil constriction in response to light Correct Explanation: 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.

Which teaching strategy would be most effective for a 7-year-old who is learning how to check blood sugars?

Re-demonstration

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? a) Temperature b) Lung sounds c) Respirations d) Blood pressure

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

Which finding would the nurse interpret as least significant when assessing a child's lungs?

Rhonchi RATIONALE: Rhonchi is the sound of air passing over mucus in the airway. Stridor and wheezing denote a constricted airway. Crackles denote fluid in alveoli, which is the mark of pneumonia.

The nurse is auscultating the heart of a 6-month-old. Which of the following findings would warrant further investigation? a) Heart rate of 120 b) Variation in heart rate during the 60 second auscultation c) S1 varies in intensity.

S1 varies in intensity. Correct Explanation: The S1 should not vary in intensity at a particular point. If it does, this may indicate a cardiac arrhythmia, and the child should be referred for further evaluation. A split S2 at the apex occurs in many infants and young children. The other findings are within the normal range for a child of 6 months.

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? a) Petechiae b) Purpura c) Salmon nevus d) Nevus flammeus

Salmon nevus Correct Explanation: 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.

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

The child states, "I never want to be a nurse or a doctor." The nurse recognizes this statement as reflecting what level of communication?

Shared personal ideas and judgments

The nurse is working at a pediatric clinic and is preparing an infant for a well child check-up and immunizations. How should the nurse prepare the infant for the visit?

The infant should be totally unclothed during the physical examination.

The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response?

The infant's toes fan and the big toe has dorsiflexion.

Assessing skin in children is an important factor and good indicator of their overall condition. Which of the following describes cyanosis of the skin? a) Skin that is bluish b) Skin that is an olive-tone c) Skin that is yellowish d) Skin that is pink

Skin that is bluish Correct Explanation: Cyanosis is a condition where there is decreased hemoglobin in the blood. This decrease in oxygen gives the skin a bluish tone. It usually involves the lips, mouth, and trunk.

A nurse greets a 14-year-old boy in the waiting room of the hospital. He approaches the nurse and stops about 5 feet away. He nods his head in response but does not say anything. Which best describes the distance the client has positioned himself from the nurse?

Social space

A 15-year-old client with type 1 diabetes has been noncompliant with his dietary regimen. When educating the teen, what is the most important thing the nurse can do to allow the teen to be in control and involved in the decision-making process?

Speak directly to the teen and consider his input in the decisions about care and education.

A nurse conducted a health history with a 5 year old admitted with abdominal pain. The nurse stood at the bedside while talking to the mother and child. The patient was in a private room. The nurse made sure the door was closed and referred to the mother as "Mrs. Smith" whenever asking a question. Which of the following actions by the nurse was not conducive to the health history? a) Conducting it in a private room b) Referring to the mother as Mrs. Smith c) Closing the door d) Standing at the bedside

Standing at the bedside Correct Explanation: An interview is best conducted in a private room with all parties seated. If not, then the health care worker appears rushed and cannot interact at eye level. The nurse should call the parent by his or her name, because doing so lets the party know his or her input and opinions about how the child is developing are valued.

The nurse is teaching a 6-year-old girl and her mother about home care for an eye infection. Which of the communication techniques would be least effective with this child?

Standing beside the child when doing the teaching

When performing a physical examination on a child, if there is a mirror image in shape, size, and position from one side of the body to the other, the child would have which of the following? a) Symmetry b) Accommodation c) Alignment d) Retraction

Symmetry Correct Explanation: The mirror image in shape, size, and position from one side of the body to the other is known as symmetry.

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

Take the apical pulse.

To obtain an accurate heart rate in an infant, which of the following would be the most important for the nurse to do? a) Use a regular stethoscope. b) Take the apical pulse. c) Check when infant is quiet. d) Count the pulse rate for 30 seconds.

Take the apical pulse. Correct Explanation: 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 nurse is planning an education session for adolescent males on health promotion activities. Which topic should the nurse include as being the most applicable for this population?

Testicular self-examination RATIONALE: Starting in adolescence, all males need to perform testicular self-examination once a month. This is the health promotion activity in which the nurse should focus for this educational session. The reproductive cycle might be more appropriate for adolescent females. Immunization schedule and socialization would be more appropriate for younger children and parents.

Where is the PMI found in Lucy who is 5 years old? a) The PMI is at the fourth intercostal space. b) The PMI is at the clavicle. c) The PMI is at the sternum. d) The PMI is at the third intercostal space.

The PMI is at the fourth intercostal space. Correct Explanation: 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.

The nurse is interviewing an adolescent. Which of the following should the nurse recognize as an important aspect of interviewing the adolescent? a) The adolescent will talk more openly if their caregivers are in the same room. b) The adolescent will not likely share information related to sexual relationships or to use of substances. c) The adolescent should be asked if they would like a peer in the room during the interview. d) The adolescent will share more about themselves in a private conversation.

The adolescent will share more about themselves in a private conversation. Correct Explanation: 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.

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

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? a) History of illness b) The chief complaint of the child c) How the child feels school is going d) Types of medications the child is on

The chief complaint of the child Correct Explanation: 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.

When conducting the Rinne test for hearing with a school-age child, the nurse learns that the child is unable to hear the sound when the tuning fork is moved to the auditory meatus. What does this finding suggest to the nurse?

The child has minimal air conduction for hearing. RATIONALE: The Rinne test is conducted by placing the stem of a tuning fork against the mastoid bone. When the sound disappears the fork is then moved to the auditory meatus. If the sound cannot be heard at the auditory meatus, this means air conduction of sound is impaired. This does not mean that bone conduction of sound is impaired. This does not mean that the child has normal hearing. This also does not mean that the child is totally deaf.

A clinic nurse is assessing an 8 year old who comes in with a parent for a well-child visit. The child is slouching and moving very slowly into the room. What does the nurse suspect may be occurring with this child?

The child may be depressed or insecure.

The nurse is examining the heart and peripheral perfusion of an 8-year-old. The nurse will assess the apical impulse at which location? a) The fourth intercostal space just medial to the child's left midclavicular line b) The fifth intercostal space lateral to the left midclavicular line c) The fourth intercostal space at the left midclavicular line d) The fifth intercostal space medial to the left midclavicular line

The fifth intercostal space lateral to the left midclavicular line Correct Explanation: The apical pulse can be found at the fifth intercostal space lateral to the left midclavicular line in children over 7 years. 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.

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

The fourth intercostal space.

The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response? a) The infant's toes fan and the big toe has dorsiflexion. b) The infant's toes stay the way they are and the big toe has dorsiflexion. c) The infant's toes wiggle d) The infant's toes do not move.

The infant's toes fan and the big toe has dorsiflexion. Correct Explanation: When assessing the Babinski sign, the infant's foot is stroked on the lateral side. The normal response is for the toes to fan out and the big toe to dorsiflex. This sign is abnormal after 24 months of age.

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

Which of the following is a grade II heart murmur? a) The murmur is soft and hard to hear. b) The murmur is soft but easily heard. c) The murmur is loud with an associated thrill. d) The murmur is loud without an associated thrill.

The murmur is soft but easily heard. Correct Explanation: 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.

Which of the following is a grade II heart murmur? a) The murmur is soft and hard to hear b) The murmur is soft but easily heard.

The murmur is soft but easily heard. Correct Explanation: 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.

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. Most subjective data are collected through interviewing the family caregiver and the child. Subjective is the data collected from another source or data that the nurse can not assess, such as pain. No one can feel the pain the client is experiencing. Objective data is information which can be gathered by direct assessment. Getting the necessary information from the caregiver would be a form of subjective data. Taking the vital signs and visual inspection are forms of objective data.

The nurse is obtaining a client history and asks the caregiver the reason for the child's visit to the health care setting. Which of the following best describes what the nurse is doing in this process? a) The nurse is interviewing the caregiver. b) The nurse is obtaining biographical data. c) The nurse is determining the chief complaint. d) The nurse is obtaining the health history.

The nurse is determining the chief complaint. Correct Explanation: The reason for the child's visit to the health care setting is called the chief complaint. In a well-child setting, this reason might be a routine check or immunizations, whereas an illness or other condition might be the reason in another setting.

The nurse is collecting subjective data when doing which of the following? a) The nurse is reinforcing teaching with the child's caregivers. b) The nurse is taking the child's vital signs. c) The nurse is interviewing the child's caregiver. d) The nurse is weighing and measuring the child.

The nurse is interviewing the child's caregiver. Correct Explanation: Information spoken by the child or family is called subjective data. Interviewing the family caregiver and child allows you to collect information that can be used to develop a plan of care for the child.

The nurse is weighing a 20-month-old 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 nurse is weighing an 18-month-old infant who is in the clinic for a well-child visit. Which of the following actions by the nurse would be most appropriate for weighing this child? a) The nurse should lay the infant on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. b) The nurse should weigh the mother on a standing scale and then weigh her again while the mother is holding the infant. c) The nurse should ask the mother to lightly hold the infant's hands while the infant is sitting on the scale. d) The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.

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

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.

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? a) The reflex is hyperactive. b) The reflex is brisk. c) The reflex is diminished. d) The reflex is absent.

The reflex is diminished. Correct Explanation: On the four-point grading scale used in assessing deep tendon reflexes, 1+ indicates a diminished response. With 2+ as average, a grade of 3+ is brisker than average and 4+ is hyperactive. The reflex is absent at a grade of 0.

Where would the S2 "dub" sound be the loudest? a) The third intercostal space b) The second intercostal space c) The fifth intercostal space d) The fourth intercostal space

The second intercostal space Explanation: The aortic area is auscultated in the second intercostal space. Here the S2 sound is louder than S1 and is a "dub" sound.

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 mother of 2-year-old triplets is anxious and worried because one of the children, Emily, does not seem to be at the same developmental level as her siblings. If the following findings were found when doing a physical exam, which finding might indicate a need for further diagnostic testing to rule out intellectual disability in this child? a) She speaks loudly when asked a question. b) The fontanels on her head are closed. c) She blows her nose frequently. d) The tops of her ears are below the corners of her eyes.

The tops of her ears are below the corners of her eyes. Correct Explanation: The alignment of the ears is noted by drawing an imaginary line from the outside corner of the eye to the prominent part of the child's skull; the top of the ear, known as the pinna, should cross this line. Ears that are set low often indicate intellectual disability. Flaring of the nostrils might indicate respiratory distress and should be reported immediately. A child who speaks loudly, responds inappropriately, or does not speak clearly may have hearing difficulties that should be explored. It would be normal for the fontanels to be closed by this age. A child who is developing normally should be able to control her head's range of motion; any stiffness in the neck should be reported immediately.

A nurse is assessing the fontanelles of a crying newborn and notes that the posterior fontanelle pulsates and briefly bulges. What do these findings indicate?

These are normal findings.

Anthropometric measurements help determine what about a child? a) These tell how well a child sleeps. b) These tell how what grade a child should be in. c) These tell how well a child grows. d) These tell how fast a child can run.

These tell how well a child grows. Correct Explanation: Anthropometric measurements include height, weight, and age and can help determine the child's pattern of growth.

The purpose of performing a pulse oximetry measurement when taking the vital signs on a child is which of the following? a) To measure the respiratory rate b) To measure the blood pressure c) To measure the oxygen saturation d) To measure the apical pulse

To measure the oxygen saturation Correct Explanation: Pulse oximetry measures the oxygen saturation of arterial hemoglobin.

A 16-year-old girl confides in the nurse that her parents are difficult to deal with and that it stresses her out. The nurse responds by saying, "You think that's stressful, you should see some of the patients I have to deal with in here!" Which barrier to communication is this nurse demonstrating?

Topping up

The human papillomavirus (HPV) is associated with the development of cervical cancer in women. a) True b) False

True Correct Explanation: It is recommended all preteens (male and female) receive three injections of this vaccine beginning at 11 to 12 years of age.

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 testing if cranial nerve VII was intact. The cranial nerve VII is the facial nerve and can be assessed by asking to see a child's teeth, having them smile, or lift an eyebrow. In infants facial symmetry would be assessed. Cranial nerve II is assessed by testing visual fields and visual acuity. Cranial nerve IV is tested by having the child move eyes downward and inward. Cranial nerve VI is assessed by checking for the ability of the eyes to move laterally.

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? a) III b) VIII c) V d) IV

VIII Correct Explanation: 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.

A child on a cardiac monitor has been transported from the emergency room to the intensive care unit. The nurse admits the child to the unit and begins collecting data on the child. Which of the following nursing interventions would the nurse do first? a) Assess the neurological function using the Glasgow coma scale. b) Change the probe on the pulse oximeter. c) Verify that the alarms on the monitor are still properly set. d) Check the apical pulse rate using a pediatric stethoscope.

Verify that the alarms on the monitor are still properly set. Explanation: At the beginning of each shift and after transport of the patient, the nurse must check that alarms are accurately set and have not been inadvertently changed. This is true for all types of monitors. The neurological status will most likely be checked, as well as the apical pulse, but they are not priorities. The probe on the pulse oximeter is changed if needed, but not routinely and not as a priority.

The nurse is assessing the abdomen of a 3-year-old. Which of the following findings should be reported immediately? a) Rounded abdomen b) Tympany over the abdomen c) Visible peristaltic waves d) Active bowel sounds

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

The nurse is taking the health history for a toddler in the emergency department. The child's mother informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint?

Vomiting

A mother tells the nurse at the clinic she did not bring her child to have his scheduled immunization because the child had a cold. What symptoms are important for the nurse to teach the mother about contraindications for immunizations? Select all that apply.

Wheezing The child has 102ºF (38.9°C) fever 100ºF (37.8°C) fever for 3 days

When is the best time for the nurse to count 9-month-old Brad's respirations? a) When Brad is quiet in his mother's lap b) When Brad is laughing c) When Brad is in the playroom d) When Brad is crying

When Brad is quiet in his mother's lap Correct Explanation: The best time to count a child's respirations is when the child is quiet and calm. Having Brad on his mom's lap will keep him quiet and supported. During the other choices of scenarios, Brad is active and the count could give an inaccurate assessment.

As Julie performs her head-to-toe assessment on a 2-year-old child, when would she examine the child's ears? a) When Julie is finished examining the entire head and face b) When Julie is examining the head and face c) When Julie is first starting so as to get it over with d) When Julie is done with all of the exam in case the child gets upset

When Julie is done with all of the exam in case the child gets upset Correct Explanation: The nurse should do any type of intrusive examination, such as of the mouth or ears, at the end of the physical exam so as not to distress the child. The other choices all could cause distress to the child before or during the exam.

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 hearing impairment will often cause a delay or absence of normal speech and language development in a child. Toddlers typically do not vocalize the sounds of the letter 'R" and "S" until older. Purulent drainage may represent an ear infection. Oxygen at birth may be problematic for vision, but not hearing.

The nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform?

apply water soluble lubricant to the probe Applying a lubricant to the thermometer probe will help prevent pain or damage to the rectum. The correct distance to insert a rectal thermometer is no more than 1 in (2.5 cm). Inserting the probe too far can damage or perforate the rectal mucosa. An 11-month-old infant is too young to understand explanation of procedures. If resistance is felt, the nurse should not continue advancing the thermometer probe.

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 caregivers questions and document the answers 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. This provides a personal interaction between the nurse and the caregiver. If the caregiver cannot read, the nurse would help with the completion of the form by asking questions and documenting the answers. Children should not be used as interpreters or complete a form. If the child is under the age of 18 it would not be a legal document, and with a child's language skills and comprehension much-needed information could be not obtained.

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 When beginning the interview, it is best for the nurse to ask the child about the health concern. If additional information is needed, the nurse can subsequently consult the parent. 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.

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's ok for the parent to be in the room When obtaining the health history from a young adolescent, give the young adolescent (aged 11 to 14 years) the choice of whether the parent is present during the interview and examination but always allow time to talk alone with the adolescent. Asking the client to wait outside does not acknowledge the client as a person. Asking the parent to leave the room does not give the client a choice in care. Asking the client to fill out the form is not supportive and does not facilitate an exploration of health history.

The nurse is assessing a child and notes the child's nail beds are blue in color. Which action will the nurse take next?

assess an oxygen saturation level A blue discoloration occurring in nails, soles or palms indicates peripheral cyanosis and indicates decreased perfusion. The nurses would assess the client's oxygen saturation level to determine the severity before notifying the provider, documenting the finding, or assessing the client's hemoglobin level. Other actions would be dependent on the child's level and response to oxygen therapy.

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

assessing vision Hearing and vision screenings are examples of secondary prevention in health assessments. These are usually state or mandated screenings to prevent risk factors of specific diseases.

Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels (fontanelles), 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.

A nursing instructor is teaching students how to assess a newborn and emphasizes the importance of taking femoral pulses. Doing so will help to rule out which condition?

coarctation of the aorta

What can be perceived by the child when a nurse sits by the bedside to obtain a health history? Select all that apply.

concern warmth comfort The space between 18 inches to 4 feet (46 cm to 1.2 m) is sensed by most people as personal space. When the nurse sits by the side of the crib or bed or sits next to a person at home, the nurse is within this space. Warmth is an innate quality some people manifest more spontaneously than others. Basic ways that warmth is conveyed are direct eye contact, use of a gentle tone of voice, listening attentively, approaching the child within a comfortable space, and using touch appropriately. Any action that lets the nurse know a person better (e.g., taking a health history, talking about school or family or how a child feels about the present situation) not only lets the nurse plan care but allows the nurse to become increasingly comfortable with the child. Lack of trust or fear are negative experiences and would not be present in an attitude of warmth.

The nurse is caring for a child in the emergency department who is on a cardiac monitor. Which nursing action should the nurse prioritize?

confirm the alarms are set with the maximum and minimum settings Cardiac monitors are used to detect changes in cardiac function. The highest priority would be to ensure the alarms are set with maximum and minimum settings and that the alarm is turned on. Many of these monitors have a visual display of the cardiac actions. Electrodes must be placed properly to obtain accurate readings of the cardiac system. The skin is cleaned to remove dirt, lotions, and powder before the electrodes are applied. The electrode sites must be checked every two hours to detect any skin redness or irritation and to determine that the electrodes are secure.

A nurse is preparing to teach an 8-year-old recently diagnosed with diabetes how to give an insulin injection. Which is the best technique for the nurse to use?

demonstration

An 18-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.

A preschool child fell off a tricycle and broke an arm that will require surgical repair. The nurse wants to prepare the child for surgery. Which is the best technique the nurse could use to teach the child about what to expect?

dolls

The nurse is preparing a 4-year-old to go visit his older sibling in the pediatric intensive care unit (PICU). What teaching method would best help in this child's preparation?

dolls

The nurse is having trouble communicating with a hospitalized child. Which communication technique would be the most beneficial for the nurse to offer the child?

drawing pictures

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 the avoid taking rectal temperatures The RN would educate the UAP on when to avoid taking a rectal temperature, such as on an immunosuppressed client or a client with diarrhea, a bleeding disorder, or a history of rectal surgery. The unit manager would not have to be immediately notified, nor would an error report have to be completed. The temperature would not need to be reassessed at this time.

A student nurse walks into a patient's room and states, "I am a student nurse who is going to take care of you today." Which level of communication is the student using?

first level

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 normal heart rate for a toddler ranges between 90 and 140 beats per minute and the respiratory rate ranges between 20 to 37 respirations per minute. A heart rate 60 beats per minute and respiratory rate 14 breaths per minute are both below the normal range for toddler.

The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam?

in the crib facing the mom When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view.

A nurse is talking to a mother concerned about her 5-year-old son. She informs the nurse that he eats only cereal and peanut butter every day and fears that he is not getting proper nutrition. The nurse reassures the mother that even though he is eating a limited variety of foods, he is likely getting enough nutrition. Which type of teaching is this nurse practicing?

informal teaching

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 To measure the circumference of an infant's head, the nurse would measure the largest point across the skull, not including the ears, with a no stretching cloth or paper tape. The tape would be placed at the forehead just above the eyebrows and brought around the head in a taut circle just above the occiput prominence at the back of the head. The measurement is then marked on a growth chart so it can be plotted to assess adequate growth. Each of the other options depicts incorrect placement of the tape for measurement and would not provide a correct measurement of the head.

All infants should have their head circumference measured at health-assessment visits. This measurement is made from a) the middle of the forehead through the parietal prominences. b) the center of the forehead to the base of the occiput. c) just above the eyebrows through the prominent part of the occiput. d) the hairline in front to the hairline in back.

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

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. RATIONALE: Measuring heads consistently from above the eyebrows to the occiput allows measurements at different visits to be compared.

When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom? a) color b) amount c) localized or generalized d) quality

localized or generalized Correct Explanation: 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.

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

meningeal irritation A positive Kernig and Brudzinski sign are indicative a meningeal irritation and are not associated with auditory or visual problems or heart murmurs.

The nurse is performing a respiratory assessment on a black adolescent experiencing a sickle-cell crisis. Where is the best place for the nurse to check for cyanosis on this client?

mucous membranes

A nurse is teaching a 7 year old what to expect during an upcoming tonsillectomy. In this situation related to teaching, which of the following is the encoder?

nurse

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 This is an example of a open-ended question. It allows for the parent to list all the things she did and not limit the response to only one thing or a "yes" or "no." A closed-ended question only gives a person the choice to answer yes or no so it would not give the information needed to make treatment decisions. A compound question is one where a combination of more than one question is asked in a seemingly single question. This type of questioning only causes confusion and may actually provide incorrect information. A leading question is one that prompts a person to answer in a certain way. An expansive question is not asked to gain information. It is generally asked to start the thinking process.

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

A nurse is teaching children about proper nutrition and shows them the USDA "My Plate." The nurse discusses the importance of diet and daily exercise. This is an example of which type of health care?

preventive

A preschool child will require the placement of a peripherally inserted central catheter (PICC) for extended antibiotic treatment. Based on the child's developmental age, what methods of teaching could the nurse best utilize to help the child understand care for the PICC? Select all that apply.

puppets dolls handling the equipment

A nursing instructor informs students that when teaching children, they need to establish expected outcomes that are which of the following? (Select all that apply.)

specific concrete measurable

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 Temporal and axillary temperatures would be appropriate on this infant. Axillary temperatures are taken on newborns and on infants and children with diarrhea. Taking the temperature using the tympanic method is noninvasive and causes little disturbance to the infant, but it is contraindicated in this infant because of suspected ear pain. Oral temperatures usually are taken only on children older than 4 to 6 years of age who are conscious and cooperative. Rectal temperatures are contraindicated in children who have had rectal surgery, have cancer or, like this infant, who have diarrhea. Rectal temperatures are the most invasive and are used very infrequently.

When assessing children using a Snellen eye chart, you should be aware that the first number of the vision report (20/20) represents:

the distance the child stands from the chart. RATIONALE: The first number indicates the distance from the chart; the second indicates the number of the line on the chart that was read.

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 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.

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

the fourth intercostal space The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. Up until the age 4 years it is located between the 3rd and 4th intercostal space (ICS). From ages 4 to 6 years it is found at the 4th ICS medial to the left midclavicular line. From age 7 upward it is located at the 5th ICS lateral to the left midclavicular line. Heart sounds radiate and can be heard either to the right or left of the sternum but never directly over the sternum. The clavicle is located too high to hear heart sounds.

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.

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 child who has had several surgeries to correct a congenital defect is found crying after receiving the news another surgery will be needed. The nurse could best assist this child through what form of communication?

touch

The nurse is communicating with a family about their child's illness. Which communication technique would be considered a block to effective communication with the family?

using clichés

Which is most likely to encourage parents to talk about their feelings related to the poor prognosis their child has been given?

using open-ended questions

The nurse is taking health history for a toddler in the emergency department. The child's mother informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection 6 weeks ago. What would the nurse recognize as is the patient's chief concern/complaint? a) pneumonia b) asthma c) vomiting d) UTI

vomiting Correct Explanation: The chief concern/complaint is the reason that the patient is seeking current health care and, in this case, is vomiting. The pneumonia, UTI, and asthma are part of the past medical history.

A nurse caring for a young patient with sickle-cell crisis always establishes eye contact, uses a gentle tone of voice, listens carefully to whatever the patient says, and uses touch appropriately. Which of the following is the nurse demonstrating by these actions?

warmth

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 caregivers lap Allow some freedom of movement when possible; child may stand between seated caregiver's legs or sit on the lap of the caregiver. Lying on the examination table with the caregiver right beside the child would be the preferred location for an infant. Sitting on the examination table with eye contact would be the best location for a school-aged child. Sitting on the examination table with the caregiver outside the room would be appropriate with early or late teenaged 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. Which of the following will she need? (Select all that apply.) a) Syringe b) Ophthalmoscope c) Tongue depressor d) IV bag e) Thermometer f) Stethoscope

• Ophthalmoscope • Tongue depressor • Thermometer • Stethoscope Correct Explanation: When performing a complete physical assessment, you'll need the following equipment: a thermometer, a stethoscope, a tongue depressor, an ophthalmoscope, an otoscope, a sphygmomanometer, a tape measure, a tuning fork, a reflex (percussion) hammer, examination gloves, and perhaps a client drape or gown. A syringe or IV bag would not be needed.

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. The nurse will: (Select all that apply.) a) Conclude this is a grade 3 heart murmur. b) Refer the child for further evaluation. c) Record the location and timing of the sounds. d) Auscultate with the child lying down. e) Auscultate with the child sitting up.

• Refer the child for further evaluation. • Record the location and timing of the sounds. • Auscultate with the child lying down. • Auscultate with the child sitting up. Correct Explanation: 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.

The nurse is taking vital signs on a 6-month-old infant. The caregiver reports that over the past 12 hours, the child has had vomiting, diarrhea, and has been pulling on his ears. Which of the following methods would be appropriate for taking this child's temperature? Select all that apply. a) Rectal b) Tympanic c) Oral d) Axillary e) Temporal

• Temporal • Tympanic • Axillary Explanation: Temporal, tympanic, and axillary temperatures would be appropriate on this child. Axillary temperatures are taken on newborns and on infants and children with diarrhea. Taking the temperature using the tympanic method is noninvasive and causes little disturbance to the child. Oral temperatures usually are taken only on children older than 4 to 6 years of age who are conscious and cooperative. Rectal temperatures are contraindicated in children who have had rectal surgery or who have diarrhea.

The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response? a) The infant's toes stay in the normal position and the big toe has dorsiflexion. b) The infant's toes fan and the big toe has dorsiflexion. c) The infant's toes wiggle. d) The infant's foot moves back and forth.

• Tympanic • Axillary • Temporal Correct Explanation: Temporal, tympanic, and axillary temperatures would be appropriate on this child. Axillary temperatures are taken on newborns and on infants and children with diarrhea. Taking the temperature using the tympanic method is noninvasive and causes little disturbance to the child. Oral temperatures usually are taken only on children older than 4 to 6 years of age who are conscious and cooperative. Rectal temperatures are contraindicated in children who have had rectal surgery or who have diarrhea.