PrepU - CH. 31 Assessing children and adolescents

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child?

5 year old

A nurse knows that a visual acuity of 20/20 is achieved at what year of age?

6

A mother visits the clinic for a routine visit with her 5-year-old son. The mother asks the nurse when the child's permanent teeth will erupt. The nurse should explain to the mother that permanent teeth usually begin to erupt by age

6 years. Permanent teeth begin forming in the jaw by age 6 months and begin to replace temporary teeth at age 6 years, usually starting with the central incisors.

The nurse is performing education to parents of elementary school children. The nurse tells the parents that the most common symptoms children complain are include what? Select all that apply.

Abdominal pain Leg pain Headache

After the age of 2 years, how much do toddlers grow per year?

About 5 cm

The nurse is assessing a teenage client who has reached puberty. What glands would the nurse know have become active?

Apocrine Apocrine (sex) glands become active at puberty. Eccrine, pineal, and parathyroid have been active since birth.

A nurse auscultates the heart rate in a young child and notes an irregular rhythm. No other abnormal vital signs are present and the child is not in any distress. What is an appropriate action by the nurse in regards to this finding?

Count the apical pulse for a full minute to obtain an accurate rate

The nurse documents that an adolescent female is in Tanner's stage 4 of pubic hair. What did the nurse most likely assess in this client?

Dark, curly, and abundant on mons pubis with no growth on medial thighs

A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding?

Document the finding in the child's chart The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute. The nurse should record this normal finding in the child's chart.

The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?

It is likely a breast bud which is a normal finding at this age.

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect?

Mastitis Redness, edema, and tenderness in the breasts indicate mastitis. Enlargement of the breasts in adolescent boys suggests gynecomastia. Masses in the adolescent female breast usually indicate cysts or trauma. Breast development before age 8 may indicate precocious puberty or thelarche.

The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child?

On the parent's lap A toddler can remain in the parent's lap to decrease anxiety. An examination table may increase anxiety, a stool is not safe and a toddler will not remain inactive long enough to stand

A nurse assesses a child with a large, irregular, macula patch on the face. What is the correct term that the nurse should use to document this finding?

Port wine stain

A teenage client shows symptoms of human papillomavirus during a health surveillance visit. What is the first action the nurse should take to educate the client about the condition?

Reassure the client that findings will remain confidential To help the client understand the situation, the first thing to do is reassure the client this will be kept confidential, even from the client's parents. Explaining the susceptibility to infection and describing all the risks of unprotected sex will be ineffective if the client is worried about confidentiality. Also, being open and respectful of the client's decision to have sex will greatly help deliver preventative messages.

he nurse is assessing a 3-year-old child. The history reveals that the bilirubin level for this child postnatally was 30 mcg/dL. What is the nurse's priority assessment based on this value?

Reflexes Extremely elevated postnatal bilirubin levels (greater than or equal to 25 mcg/dL) may be associated with neurological problems. Therefore, assessing reflexes, as part of a neurological assessment for this child, is priority. Blood pressure, rectal temperature, and kidney function are not part of a neuro exam.

The nurse is conducting a health history with an adolescent client. What should the nurse explain to the client about confidentiality?

The only thing that I must share is information that concerns your safety.

The nurse determines the heart rate of 100 beats per minute for a 5-year-old client as being:

Within normal limits The average heart rate of a 5-year-old client is 103 beats per minute, with the range being from 68 to 138 beats per minute. Sinus bradycardia is a heart rate less than 60 in a 5-year-old client. A heart rate of 100 beats per minute in a 5-year-old client is not evidence of a valve disorder. A heart rate of up to 240 beats per minute would be assessed in supraventricular tachycardia.

A child is repeatedly observed using the hand to push the nose upwards and backwards. What associated physical sign should the nurse assess for?

discoloration of the lower orbitopalpebral grooves

While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of

iron

The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse?

perianal lacerations extending to external sphincter

Which assessment finding is commonly observed in clients diagnosed with streptococcal pharyngitis (strep throat)?

petechiae on the roof of the mouth

A pre-teen client has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this client, what would be the most appropriate intervention?

provide information that contributes to an improved state of health

While assessing the skin, hair, and nails of a 4-year-old boy, the nurse can anticipate that the child will have

smooth-textured skin. During early childhood, the skin develops a tighter bond with the dermis, making it more resistant to infection, irritation, and fluid loss. Skin color appears pink and evenly distributed and may include normal variations such as freckles. The texture is smooth because the skin has not had years of exposure to the environment and because the hair is less coarse than in adulthood.

After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be

stage 2

The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding?

this a normal finding for a toddler

Which assessment questions are appropriate when assessing an adolescent? Select all that apply.

-"How would you describe your relationship with your parents?" -"What do you think is your best characteristic?" -"What types of food do you like to eat?" -"How are you doing with your schoolwork?" It is appropriate to include questions concerning family functioning, opinion of self, eating habits, and school performance. Parents' concerns should be discussed with the parents.

The school nurse understands that which of the following children require the administration of purified protein derivative tuberculin tests to screen for exposure to tuberculosis? (Select all that apply.) -A child infected with human immunodeficiency virus (HIV) -A child who traveled to the Midwest United States to visit grandparents for the summer -A child living in a home with a sister who is an intravenous substance abuser -A child who moved from a third world country -A child whose parent is in the military

-A child infected with human immunodeficiency virus (HIV) -A child living in a home with a sister who is an intravenous substance abuser -A child who moved from a third world country

The nurse is preparing topics to discuss healthy habits and behaviors with a school-aged client and parents. What will the nurse include in this teaching? (Select all that apply.) -Healthy meals and snacks -Use of a car seat -Avoiding tobacco exposure -Routine dental examinations -Avoiding sun exposure

-Healthy meals and snacks -Avoiding tobacco exposure -Routine dental examinations -Use of a car seat

During a routine health supervision visit, the nurse is planning to focus teaching on behaviors and habits with an adolescent client. What topics will the nurse discuss with the client? (Select all that apply.)

-Nutrition -Exercise -Computer screen time

The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age?

3

The nurse is planning a presentation on childhood growth and development to a group of new parents. Which of the following should the nurse include in the teaching plan?

A child's head reaches 90% of its full growth by 6 years of age.

The school nurse has received approval to begin a series of health classes for adolescents focusing on contraception and sexually transmitted infections (STIs). What would be the importance of targeting adolescents?

Adolescents are more likely than adults to have multiple sex partners and engage in unprotected sex.

A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?

Allow the child to place the hand under the examiner's hand To decrease ticklishness, have the child help by placing the hand under the nurse's hand, using age-appropriate distraction and conversation focused on something other than the exam.

How can a nurse help to decrease stress and embarrassment when examining the external genitalia of a young female child?

Allow the child to use their hands to spread the labia

A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?

Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

A nurse understands that which sleep pattern is considered normal for a preschooler?

Sleep 11 to 13 hours per day

A mother bring her 18 month old toddler to the clinic for a well visit checkup. The nurse perform which action during the child's assessment?

Measure height while recumbent Growth charts for children from birth to 2 years old are for heights measured while recumbent; charts for children 2 to 18 years of age are for children measured upright with a stadiometer. Children are weighed on a calibrated scale. For children older than 2 years of age, health care providers calculate and plot body mass index (BMI). Head circumference, not abdominal circumference, is measured on children from birth to 3 years old and plotted on similar growth charts.

A nurse measures an 18-month-old child's head circumference (HC) and finds that it is in the 3rd percentile. Which of the following conditions should the nurse suspect in this child?

Microcephaly HC not within the normal percentiles may indicate pathology. A finding greater than 95% may indicate macrocephaly. A finding under the 5th percentile may indicate microcephaly. Increased HC in children older than 3 years may indicate separation of cranial sutures due to increased intracranial pressure.

Upon inspection of the external eyes of a child, which position should indicate to the nurse that the eyes are properly located?

Outer canthus aligns with the tip of the pinna

While assessing the head and neck of an 11 year old child, the nurse palpates several tender and swollen lymph nodes. What is the nurse's best action?

Prepare to collect blood to analyze white blood cell count.

A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention?

Raise head of bed and apply oxygen Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually occurs from a respiratory disorder or significant blood loss. Children rarely present in acute distress from ischemic heart disease and resulting dysrhythmias. The child in respiratory distress presents with nasal flaring and chest retractions or abdominal breathing. Administration of oxygen and support of the child's ability to breathe are the first interventions. Then a medical history and list of medications can be obtained.

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage?

Relative sexual indifference and interaction with same-sex peers

While performing cardiac auscultation of a young child, the nurse detects a pulmonary flow murmur that is accompanied by a fixed split second heart sound. What does this suggest?

Right-heart volume load A pulmonary flow murmur accompanied by a fixed split-second heart sound suggests right-heart volume load such as an atrial septal defect.

On assessment, pertussis is identified by what characteristic sign?

a violent cough with a "whoop" sound at the end

A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action?

apply oxygen via nasal cannula

The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?

ask the mother to leave the room

When assessing the vital signs of a toddler, a nurse records normal temperature, pulse, and respiration, but an elevated blood pressure. What is the initial responsibility of the nurse?

check for size of the cuff

A 12 year old adolescent female presents to the clinic alone requesting birth control and testing and treatment suspected chlamydia. What is the nurse's priority action?

check state regulations about testing and treatment of minors

The nurse is caring for a hospitalized adolescent with sickle cell crisis. While communicating with the client, the nurse should

give the client control whenever possible.

While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is

play. Play is one of the most valuable communication techniques when working with children; it allows for the discovery of important clues to children's development and illness behaviors.

The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to

hop on one foot.

The nurse is assessing a 4-year-old child with a temperature of 37.7 °C (100 °F). The nurse observes that the client has Koplik spots on his buccal mucosa. The nurse should explain to the client's parents that the child is most likely exhibiting signs of

measles.

A 3-year-old child has arrived at the clinic for a physical exam. The nurse should perform which action when completing the growth chart?

obtain head circumference and plot results on the growth chart

A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that

she can begin bowel training as soon as the child appears ready. Toilet training is a major task of toddlerhood. Readiness is not usual until 18 to 24 months of age. Bowel training occurs before bladder; night bladder training usually does not occur until 3 to 5 years of age.

The nurse is preparing to assess a 5-year-old child. To perform the Hirschberg test, the nurse should

shine a light directly into the pupils

When examining the testicles of a young male child, how can a nurse facilitate the exam without eliciting the cremasteric reflex?

sit with knees flexed and abducted

Your client is a 15-year-old male. His testes and scrotum are enlarged and the scrotal skin is darkened. His pubic hair is coarse and curly but does not extend to the thighs. What Tanner stage would you assign to this client?

stage 4

A woman who speaks primarily Spanish at home brings her 3-year-old to the clinic for a yearly visit. The mother reports concern that her child's language skills are not progressing as expected. The health care provider may have a difficult time assessing this child's language capabilities if

the provider is not bilingual

The nurse is assessing a young adolescent female client using Tanner Sexual Maturity Rating for Breast Development. The nurse determines that the client has enlargement of the breasts and areolae, with no separation of contours. The client is in Tanner Stage

three.

A nurse is documenting findings for an adolescent client. Which of the following should the nurse do?

use a sequential approach

The nurse is performing an assessment on a toddler. What finding would be expected?

visual acuity 20/200