Chapter 29: Assessment

A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply)

- Asymmetry of the shoulders. - An uneven hemline. - Unequal waist angles.

A nurse is performing an assessment on a school-age child. Which findings suggest the child is receiving an excess of vitamin A? (Select all that apply)

- Delayed sexual development. - Pruritis. - Jaundice.

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply)

- Elicit one answer at a time. - Arrange for the family to speak with the same interpreter, if possible. - Introduce the interpreter to the family.

Which data would be included in a health history? (Select all that apply)

- Review of systems. - Sexual history. - Nutritional assessment. - Family medical history.

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply)

- The cuff bladder width is approximately 40% of the circumference of the upper arm. - The cuff bladder length covers 80% to 100% of the circumference of the upper arm.

By what age do the head and chest circumferences generally become equal?

1-2 years.

The nurse should expect the anterior fontanel to close at age?

12-18 months.

The earliest age at which a satisfactory radial pulse can be taken in children is?

2 years.

Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age?

3 to 4 months.

The nurse is testing an infants visual acuity. By what age should the infant be able to fix on and follow a target?

3 to 4 months.

With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)for-age percentile indicates a risk for being overweight?

85th percentile.

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is?

A normal finding.

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as?

A way to establish rapport.

When the nurse interviews an adolescent, it is especially important t

Allow an opportunity to express feelings.

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are?

An important part of the child's past growth and development.

The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to:

Ask her, "Are you having sex with anyone?".

The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined?

Ask the adolescent, "Why did you come here today?"

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique may be most helpful?

Ask the child to draw a picture.

The nurse is interviewing the mother of an infant. She reports, I had a difficult delivery, and my baby was born prematurely. This information should be recorded under which heading?

Birth history.

Which tool measures body fat most accurately?

Calipers.

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the finger-to-nose test. The nurse is testing for?

Cerebellar function.

An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to:

Explain in simple terms how it works.

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is?

Infection or inflammation close to the site.

The nurse must assess 10-month-old infant. The infant is sitting on the fathers lap and appears to be afraid of the nurse and of what may happen next. Which initial action by the nurse would be most appropriate?

Initiate a game of peek-a-boo.

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?

Introduce himself or herself.

The nurse has a 2-year-old boy sit in tailor position during palpation for the testes. The rationale for this position is that?

It prevents cremasteric reflex.

When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet?

May provide sufficient amino acids.

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?

Murmur.

During examination of a toddlers extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is?

Normal because the lower back and leg muscles are not yet well developed.

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

Oral mucosa.

The nurse must assess a child's capillary filling time. This can be accomplished by?

Palpating the skin to produce a slight blanching.

Where in the health history should the nurse describe all details related to the chief complaint?

Present illness.

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. The most appropriate action is to?

Refer for immediate medical evaluation.

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurses most appropriate action?

Refer the child for further evaluation.

Which age group is most concerned with body integrity?

School-age child.

The most frequently used test for measuring visual acuity is the?

Snellen letter chart.

The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that?

The NCHS charts are accurate for U.S. African-American children.

When introducing hospital equipment to a preschooler who seems afraid, the nurses approach should be based on which principle?

The child may think the equipment is alive.

What is the single most important factor to consider when communicating with children?

The child's developmental level.

The appropriate placement of a tongue blade for assessment of the mouth and throat is the?

The side of the tongue.

Which parameter correlates best with measurements of the bodys total protein stores?

Upper arm circumference.

An appropriate approach to performing a physical assessment on a toddler is to?

Use minimal physical contact initially.

Which action is most likely to encourage parents to talk about their feelings related to their child's illness?

Use open-ended questions.

What is an important consideration for the nurse who is communicating with a very young child?

Use transition objects such as a doll.

What type of breath sound is normally heard over the entire surface of the lungs, except for the upper intrascapular area and the area beneath the manubrium?

Vesicular.

What term is used to describe breath sounds that are produced as air passes through narrowed passageways?

Wheezing.