ATI comprehensive physical assessment of a child
A nurse is inspecting the thorax of an infant. Which of the following findings should the nurse expect?
A barrel shaped chest in which the anterior-posterior are equal. Note: Should expect primarily abdominal movement with respiration until young school age. During infancy the chest and head circumference should be roughly the same size.
A nurse is performing an abdominal assessment on a preschooler. Which of the following actions should the nurse take during the assessment?
Ask the child to "help" with the exam by placing their hand on top of the nurse's hand Note: Encouraging the child to assist with the examination will promote distraction and relaxation of the abdominal wall muscles. Note: Palpate tenderness last, child should be placed in knees flexed position to promote relaxation of abdominal wall prior to palpating, taking a deep breath will tense the abdominal muscles.
A nurse is performing a screening for scoliosis on a school-age child. Which of the following instructions should the nurse provide?
Bend forward with your knees straight and your arms dangling Note that this position allows for adequate visualization to detect any asymmetry of the spine or rib cage.
A nurse is expecting the skin of a toddler. Which of the following findings should the nurse report to the provider?
Ecchymotic area on the abdomen
A nurse is preparing to perform a physical assessment on a 10 year old child. Which of the following interventions should the nurse plan to implement?
Explain how the equipment works using correct medical terminology Note: School age children are interested in learning and building language skills. Therefore the nurse should explain the function of the equipment using the correct terminology. Allow the child to touch and play with equipment is used for toddlers, preschoolers and young school age children. Play games while performing the examination is with toddlers and uncooperative preschoolers to reduce their anxiety. Discuss the benefits of performing the technique is best used with adolescents because discussing the benefits and long term consequences of the exam requires abstract thinking. This developmental skill does not appear until adolescence.
The nurse is performing a cardiac assessment on a preschooler. The nurse should plan to auscultate the apical pulse at which of the following precordial landmarks?
Left of the midclavicular line at the fourth intercostal space Note that this is where it will be for those who are younger than 7. It will be in the 5th intercostal space for those over 7.
A nurse is preparing to obtain a temperature on an 18 month old toddler during a well child examination. Which of the following actions should the nurse take?
Place the thermometer tip in the center of the toddler's axilla against their skin Note: Axillary method should be used. Should not use oral electronic thermometer to assess toddlers temperature because children younger than 5 years old have difficulty holding the temp probe under their tonuge. Rectal temperature assessment is invasive and upsetting to young children,. A tympanic thermometer should not be used to assess the temperature of a child who is younger than 2 years old due to the small size of the ear canal.
A nurse is assessing the reflexes of a 6 month old infant. Which of the following reflex findings should the nurse expect?
Positive Babinski reflex Note: Babinski reflex is elicited by stroking up the side of the foot and across the ball of the foot. A positive Babinski reflex is present when this action causes the toes to fan outwards. This is expected finding through the first year of life, after which it begins to fade. Positive extrusion reflex is elicited when the infants tongue is depressed or touched. It is positive and present when the infant responds by forcing their tongue outward, the reflex should disappear by 4 months. Plantar grasp reflex is elicited by touching the foot at the base of the toes. A positive plantar grasp reflex is present when the toes curl downwards in response to this action. This is an expected finding in a 6 month old infant. Sucking reflex: is elicited by touching the lips, a positive sucking reflex is present when the infant responds to touch with strong sucking movement if the circumoral area. This is expected throughout the first year of life.
A nurse is obtaining the blood pressure of a school age child. Which of the following actions should the nurse take?
Select a cuff width that covers 40% of the upper arm Note: Using a blood pressure cuff that is too large or too small will lead to inaccurate blood pressure measurement. Therefore the nurse should inspect the limb size of the child and choose a cuff which covers 40 % of the upper arm circumference. The cuff bladder length should encircle 80 to 1000% of the upper arm. Cuff pressure should be released at a rate of 2 to 3 mm HG per second Arm should be position and supported with the cubital fossa at the level of the heart.
A nurse is performing an annual physical examination on an adolescent. Which of the following should the nurse include in the general survey?
The adolescent makes good eye contact Note that this should be included in general survey which includes identifying clients demeanor, mood and interactions with others. DTR = Neurological Visual Acuity = eye exam Fine motor = neurological
