Ch. 31 Assessing Children and Adolescents

A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia

15. A young boy is found squirting lighter fluid into his mouth. His father calls the emergency department. The nurse taking the call should know that the primary danger is which result? a. Hepatic dysfunction b. Dehydration secondary to vomiting c. Esophageal stricture and shock d. Bronchitis and chemical pneumonia d. Bronchitis and chemical pneumonia

Which of the following techniques is appropriate when obtaining a blood pressure on a child

Use a cuff with bladder covering 80 to 100% of the arm circumference

Which of the following communication techniques is most appropriate fro a nurse to employ during the physical examination of a 10 year old

Use books and other visual aids to advance the interview

Which is the leading cause of death during the toddler period? a. Injuries b. Infectious diseases c. Congenital disorders d. Childhood diseases

a. Injuries

A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, "Wait a minute" and "I'm not ready." The nurse should recognize this as which description? a. This is normal behavior for a school-age child. b. The behavior is not seen past the preschool years. c. The child thinks the nurse is punishing her. d. The child has successfully manipulated the nurse in the past.

a. This is normal behavior for a school-age child.

In terms of fine motor development, what should the infant of 7 months be able to do? a. Transfer objects from one hand to the other and bang cubes on a table. b. Use thumb and index finger in crude pincer grasp and release an object at will. c. Hold a crayon between the fingers and make a mark on paper.

a. Transfer objects from one hand to the other and bang cubes on a table.

The nurse is performing a physical assessment on a 6-month_ord baby. Which finding should the nurse understand is abnormal for this child?

a. The childs posterior fontanel is open

A parent asks the nurse "when will my infant start to teethe?" The nurse responds that the earliest age at which an infant begins teething with eruption of lower central incisors is _____ months. a. 4 b. 6 c. 8 d. 12

b. 6

When assessing a school age child for scoliosis, it is important to have the child

bend forward with the knees straight and the arms dangling

At what age should the nurse expect the anterior fontanel to close? a. 2 months b. 2 to 4 months c. 6 to 8 months d. 12 to 18 months

d. 12 to 18 months

The most common cause of death in the adolescent age group involves: a. drownings. b. firearms. c. drug overdoses. d. motor vehicles.

d. motor vehicles.

A 2-day-old qirl is being discharged from the hospital. Her mother asks the nurse when she will receive her first Hep B vaccine. Which is the nurses best response?

"She will receive her first dose of the hepatitis B vaccine prior to discharge today

By what age does birth length usually double? a. 1 year b. 2 years c. 4 years d. 6 years

4 years

A 3-year-old female is hospitalized for a femur fracture. fu her nurse, what nursing action would help foster the child's sense of autonomy?

Allow the child to administer her own dose of Keflex (cephalexin) via oral syringe.

An 8-year-old is NPo while he awaits surgery for central line placement later in the afternoon. The nurse is trying to engage the child in some form of activity to distract him from thinking about his upcoming surgery. Which is the best distraction for a child of this age in this situation?

Encourage the child to play a board game

In order to prevent separation anxiety in a hospitalized toddler, which of the following should the nurse do?

Establish a routine that is similar to that of the child's home

The nurse is caring for a 6-month-old in the ER. The physician orders the nurse to give the child a dose of Rocephin IM. The 1.5-mL dose arrives from the pharmacy. The nurse should do which of the following?

Split the dose into two injections

The nurse is-caring for a 7-year-old female on the school-age unit. Her mother is concerned that she may have some developmental delays. Which of the following statements would indicate to the nurse that the child is not developmentally on track for her age:

The child has an imaginary friend named Kelly

A 5-year-old is at the pediatrician's office for his well-child checkup. The nurse will be administering three immunizations to the child. Then nurse should expect which reaction from the child when she gives his immunization

The child will likely cry and tell the nurse that it hurts

3 y/o was admitted to the hospital with croup. His nurse just obtained vital signs. HR 90, RR 44, BP 100/52, T 98.8F. the parents ask the nurse is his vitals are appropriate for a child his age. The nurses best response to the parents is:

Your sons RR is elevated, but the other vitals are WNL

A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age? a. 6 to 8 weeks b. 10 to 12 weeks c. 4 to 6 months d. 8 to 10 months

a. 6 to 8 weeks

Samantha, age 5 years, tells the nurse that she "needs a Band-Aid" where she had an injection. Which is the best nursing action? a. Apply a Band-Aid. b. Ask her why she wants a Band-Aid. c. Explain why a Band-Aid is not needed. d. Show her that the bleeding has already stopped

a. Apply a Band-Aid.

A nurse is planning a class on accident prevention for parents of toddlers. Which safety topic is the priority for this class? a. Appropriate use of car seat restraints b. Safety crossing the street c. Helmet use when riding a bicycle d. Poison control numbers

a. Appropriate use of car seat restraints

Which aspect of cognition develops during adolescence? a. Capability to use a future time perspective b. Ability to place things in a sensible and logical order c. Ability to see things from the point of view of another d. Progress from making judgments based on what they see to making judgments based on what they reason

a. Capability to use a future time perspective

Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which will help her most in her adjustment to the hospital? a. Explain hospital schedules to her, such as mealtimes. b. Use terms such as "honey" and "dear" to show a caring attitude. c. Explain when parents can visit and why siblings cannot come to see her. d. Orient her parents, because she is young, to her room and hospital facility.

a. Explain hospital schedules to her, such as mealtimes.

A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child? a. Focus communication on child. b. Explain experiences of others to child. c. Use easy analogies when possible. d. Assure child that communication is private.

a. Focus communication on child.

The nurse must assess 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate? a. Initiate a game of peek-a-boo. b. Ask father to place the infant on the examination table. c. Undress the infant while he is still sitting on his father's lap. d. Talk softly to the infant while taking him from his father.

a. Initiate a game of peek-a-boo.

Four-year-old Brian appears to be upset by hospitalization. Which is an appropriate intervention? a. Let him know it is all right to cry. b. Give him time to gain control of himself. c. Show him how other children are cooperating. d. Tell him what a big boy he is to be so quiet.

a. Let him know it is all right to cry.

A nurse is preparing to administer immunizations to a 6-month-old infant. Which interventions should the nurse implement to minimize local reaction and reduce pain? (Select all that apply.)

a. Select a needle of adequate length (1 inch). c. Apply a vapocoolant spray directly to the skin, 15 seconds before administration. d. Apply a topical anesthetic LMX4 (4% lidocaine) 10 minutes before administration.

A nurse is caring for four patients; three are toddlers and one is a preschooler. Which represents the major stressor of hospitalization for these four patients? a. Separation anxiety b. Loss of control c. Fear of bodily injury d. Fear of pain

a. Separation anxiety

Which statement is true about smoking in adolescence? a. Smoking is related to other high-risk behaviors. b. Smoking will not continue unless peer pressure continues. c. Smoking is less common when the adolescent's parent(s) smokes. d. Smoking among adolescents is becoming more prevalent.

a. Smoking is related to other high-risk behaviors.

The nurse's approach when introducing hospital equipment to a preschooler should be based on which principle? a. The child may think the equipment is alive. b. The child is too young to understand what the equipment does. c. Explaining the equipment will only increase the child's fear. d. One brief explanation will be enough to reduce the child's fear.

a. The child may think the equipment is alive.

A parent of an 18-month-old boy tells the nurse that he says "no" to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurse's best interpretation of this behavior is included in which statement? a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention.

a. This is normal behavior for his age.

A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as: a. normal development. b. significant developmental lag. c. slightly delayed development due to prematurity. d. suggestive of a neurologic disorder such as cerebral palsy.

a. normal development. Holding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. The infant is expected to be able to perform this task by age 3 months. If the child's age is corrected because of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task and the behavior is age appropriate. No evidence of neurologic dysfunction is present.

The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. The nurse should interpret this as a(n): a. normal finding. b. finding requiring a referral. c. abnormal finding. d. normal finding, but requires rechecking in 1 month.

a. normal finding.

When a preschool child is hospitalized without adequate preparation, the nurse should recognize that the child may likely see hospitalization as: a. punishment. b. threat to child's self-image. c. an opportunity for regression. d. loss of companionship with friends.

a. punishment.

A 3-year-old female is hospitalized for an ASD repair. Her parents have decided to go home for a few hours to spend time with her siblings. The child asks when her mommy and daddy will be back. The nurse's best response is:

a. "Your mommy and daddy will be back after your nap."

60. a 4 year-old has been hospitalized with FTT. The child has orders for daily weights' Strict input and output, and calorie count as a means of measuring her nutritional status. Which action by the nurse would be a concern?

a. The nurse weighs the child every morning before the child eats breakfast

which statement by the mother of an 18-month-old would lead the nurse to believe that the child should be referred for further evaluation for developmental delay

a. child is able to stand but is not yet taking steps independently."

What is the earliest age at which a satisfactory radial pulse can be taken in children? a. 1 year b. 2 years c. 3 years d. 6 years

b. 2 years

Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that binocularity is normally present by what age? a. 1 month b. 3 to 4 months c. 6 to 8 months d. 12 months

b. 3 to 4 months

When the nurse interviews an adolescent, which is especially important? a. Focus the discussion on the peer group. b. Allow an opportunity to express feelings. c. Emphasize that confidentiality will always be maintained. d. Use the same type of language as the adolescent.

b. Allow an opportunity to express feelings.

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined? a. Ask for detailed listing of symptoms. b. Ask adolescent, "Why did you come here today?" c. Use what adolescent says to determine, in correct medical terminology, what the problem is. d. Interview parent away from adolescent to determine chief complaint.

b. Ask adolescent, "Why did you come here today?"

A school nurse notes that school-age children generally obey the rules at school. The nurse recognizes that the children are displaying which stage of moral development? a. Preconventional b. Conventional c. Post-conventional d. Undifferentiated

b. Conventional Conventional stage of moral development is described as obeying the rules, doing one's duty, showing respect for authority, and maintaining the social order. This stage is characteristic of school-age children's behavior.

A 12-year-old child enjoys collecting stamps, playing soccer, and participating in Boy Scout activities. The nurse recognizes that the child is displaying which developmental task? a. Identity b. Industry c. Integrity d. Intimacy

b. Industry Industry is engaging in tasks that can be carried through to completion, learning to compete and cooperate with others, and learning rules. Industry is the developmental task characteristic of the school-age child.

The nurse is preparing an in-service education to staff about atraumatic care for pediatric patients. Which intervention should the nurse include? a. Prepare the child for separation from parents during hospitalization by reviewing a video. b. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal. c. Help the child accept the loss of control associated with hospitalization. d. Help the child accept pain that is connected with a treatment or procedure

b. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal.

A visitor arrives at a daycare center during lunch time. The preschool children think that every time they have lunch a visitor will arrive. Which preoperational characteristic is being displayed? a. Egocentrism b. Transductive reasoning c. Intuitive reasoning d. Conservation

b. Transductive reasoning Transductive reasoning is when two events occur together, they cause each other. The expectation that every time lunch is served a visitor will arrive is descriptive of transductive reasoning.

What is an important consideration for the nurse who is communicating with a very young child? a. Speak loudly, clearly, and directly. b. Use transition objects, such as a doll. c. Disguise own feelings, attitudes, and anxiety. d. Initiate contact with child when parent is not present.

b. Use transition objects, such as a doll.

The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include: a. forcing fluids. b. monitoring pulse oximetry. c. instituting seizure precautions. d. encouraging a high-protein diet.

b. monitoring pulse oximetry.

the first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was dis- charged 4 days ago. The nurse's best response to the mother is:

b. "An initial weight loss of a few ounces is common among newborns, especially for breastfeeding mothers."

A male infant is visiting the pediatrician for his 6-month well-child checkup. His mother tells the nurse she wants to advance the infant's diet. Which statement by the infant's mother leads the nurse to believe that she needs further education about the nutritional needs of a 6-month-old?

b. "I will start my son on fruits and gradually introduce vegetables'"

The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately how many pounds? a. 10 b. 15 c. 20 d. 25

b. 15

Kimberly's parents have been using a rearward-facing, convertible car seat since she was born. Most car seats can be safely switched to the forward-facing position when the child reaches which age? a. 1 b. 2 c. 3 d. 4

b. 2

A mother requests that her child receive the varicella vaccine at her 9-month well-child checkup. The nurse tells the mother that:

b. The nurse cannot give the vaccine.

The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statement by the adolescent should be expected about separation anxiety? a. "I wish my parents could spend the night with me while I am in the hospital." b. "I think I would like for my siblings to visit me but not my friends." c. "I hope my friends don't forget about visiting me." d. "I will be embarrassed if my friends come to the hospital to visit."

c. "I hope my friends don't forget about visiting me."

A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age? a. 1 month b. 6 to 9 months c. 1 to 2 years d. 2 1/2 to 3 years

c. 1 to 2 years

At about what age does the Babinski sign disappear? a. 4 months b. 6 months c. 1 year d. 2 years

c. 1 year

At what age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months

c. 8 months

A child has been diagnosed with enuresis. TCA imipramine (Tofranil) has been prescribed for the child. The nurse understands that this medication is in which category? a. Antidepressant b. Antidiuretic c. Antispasmodic d. Analgesic

c. Antispasmodic

The child of 15 to 30 months is likely to be struggling with which developmental task? a. Trust b. Initiative c. Autonomy d. Intimacy

c. Autonomy

A nurse is assessing a 12-month-old infant. Which statement best describes the infant's physical development a nurse should expect to find? a. Anterior fontanel closes by age 6 to 10 months. b. Binocularity is well established by age 8 months. c. Birth weight doubles by age 5 months and triples by age 1 year. d. Maternal iron stores persist during the first 12 months of life.

c. Birth weight doubles by age 5 months and triples by age 1 year.

A 12-year-old male has short stature because of a constitutional growth delay. The nurse should be the most concerned about which of the following? a. Proper administration of thyroid hormone b. Proper administration of human growth hormones c. Child's self-esteem and sense of competence d. Helping child understand that his height is most likely caused by chronic illness and is not his fault

c. Child's self-esteem and sense of competence

A nurse is preparing to complete an admission assessment on a 2-year-old child. The child is sitting on the parent's lap. Which technique should the nurse implement to complete the physical exam? a. Ask the parent to place the child in the hospital crib. b. Take the child and parent to the exam room. c. Perform the exam while the child is on the parent's lap. d. Ask the child to stand by the parent while completing the exam.

c. Perform the exam while the child is on the parent's lap.

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? a. Teach parents appropriate exercises. b. Recheck head control at next visit. c. Refer child for further evaluation. d. Refer child for further evaluation if anterior fontanel is still open.

c. Refer child for further evaluation. Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.

Which is the major cause of death for children older than 1 year? a. Cancer b. Heart disease c. Unintentional injuries d. Congenital anomalies

c. Unintentional injuries

A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child? a. Always proceed in a head-to-toe direction. b. Perform traumatic procedures first. c. Use minimal physical contact initially. d. Demonstrate use of equipment.

c. Use minimal physical contact initially.

A father tells the nurse that his child is "filling up the house with collections" like seashells, bottle caps, baseball cards, and pennies. The nurse should recognize that the child is developing: a. object permanence. b. preoperational thinking. c. concrete operational thinking. d. ability to use abstract symbols.

c. concrete operational thinking. During concrete operations, children develop logical thought processes. They are able to classify, sort, order, and otherwise organize facts about the world. This ability fosters the child's ability to create collections.

A 6-month-old male is at his well-child check-up. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurses best, response is:

c. "At 6 months his weight should be approximately twice his birth weight.,,

The nurse is instructing a new breastfeeding mother in the need to provide her premature infant with an adequate source of iron in her diet. Which one of the following statements reflects a need for further education of the new mother?

c. "I will need to add iron supplements to my baby's diet when she is 9 months old'"

An 8-week-old male has just had surgery for pyloric stenosis. His nurse is assessing his level of pain. The child's mother asks the nurse what vital sign changes she should expect to see in a child who is experiencing pain. The nurse's best response is:

c. "We expect to see a child's heart rate and blood pressure increase."

By which age should the nurse expect an infant to be able to pull to a standing position? a. 6 months b. 8 months c. 11 to 12 months d. 14 to 15 months

c. 11 to 12 months Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs. Any infant who cannot pull to a standing position by age 1 year should be referred for further evaluation.

A parent asks the nurse "at what age do most infants begin to fear strangers?" The nurse should give which response? a. 2 months b. 4 months c. 6 months d. 12 months

c. 6 months

A 7 -year old female is being admitted to the hospital for a diagnosis of acute lymphocytic leukemia. The nurse is trying to gather information from the child regarding her feelings about her diagnosis. Which nursing action is most appropriate to gain information about how the child is feeling?

c. The nurse should provide the child with some paper to draw a picture of how she is feeling.

A school nurse is teaching a group of preadolescent boys about puberty. By which age should concerns about pubertal delay be considered? a. 12 to 12 1/2 years b. 12 1/2 to 13 years c. 13 to 13 1/2 years d. 13 1/2 to 14 years

d. 13 1/2 to 14 years

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful? a. Suggest that the child keep a diary. b. Suggest that the parent read fairy tales to the child. c. Ask the parent if the child is always uncommunicative. d. Ask the child to draw a picture.

d. Ask the child to draw a picture.

Which age group should the pediatric nurse recognize as being vulnerable to events that lessen their feeling of control and power? a. Infants b. Toddlers c. Preschoolers d. School-age children

d. School-age children

Parents tell the nurse that their 1-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on which statement? a. Children should not sleep with their parents. b. Separation from parents should be completed by this age. c. Daytime attention should be increased. d. This is a common and accepted practice, especially in some cultural groups.

d. This is a common and accepted practice, especially in some cultural groups.

Acute salicylate (ASA, aspirin) poisoning results in: a. chemical pneumonitis. b. hepatic damage. c. retractions and grunting. d. disorientation and loss of consciousness.

d. disorientation and loss of consciousness.

A nurse is conducting parenting classes for parents of children ranging in ages 2 to 7 years. The parents understand the term egocentrism when they indicate it means: a. selfishness. b. self-centeredness. c. preferring to play alone. d. unable to put self in another's place.

d. unable to put self in another's place.

58. A 17-year-old male has had some recent behavioral changes. His mother calls the nurse at the pediatrician's office and tells her that her son has been coming home from school every day, closing his door, and refraining from interaction with his parents. The child's mother does not know what she should do about her son's unsociable behavior. The nurse's best response to the child's mother is:

d. "Your son's behavior is normal. You should listen to him without being judgmental."

An infant who weighs 7 pounds at birth would be expected to weigh how many pounds at age 1 year? a. 14 b. 16 c. 18 d. 21

d. 21

The parents of a 2-year-old boy are concerned about his behavior. Since the childs admission to the hospital 2 days ago he has been crying much more than usual and ls inconsolable much of the time. The nurse's best response to the child's parents is:The parents of a 2-year-old boy are concerned about his behavior. Since the childs admission to the hospital 2 days ago he has been crying much more than usual and ls inconsolable much of the time. The nurse's best response to the child's parents is:

d. The child is in the protest stage of separation anxiety which is normal for children during hospitalization.

A 5-year-old girl has been brought to the ER for suspected child abuse. What approach should the nurse use to gather information from the child?

d. The nurse should tell the child that the abuse is not her fault and that she is a good person.

A nurse is obtaining a problem-oriented history from a preschool-aged child. The nurse should consider that children form this age group typically can

describe the symptoms

When performing an otoscopy examination on a 2-year old child, the nurse should pull the pinna

down and back

A nurse is examining an 18-month-old child ears during a well child visit. Which of the following techniques should the nurse use

have the parent hold the child securely in their lap

A nurse is testing a child for strabismus. Which of the following is the correct technique fro performing this examination

perform the cover-uncover test

A nurse is performing an abdominal examination on a preschooler. Which of the following instructions should the nurse give to the child when performing abdominal palpitation

place your hand under mine

A nurse is performing an annual physical examination on an adolescent. Which of the following should be included in the general survey

the patient makes good eye contact