NUR 236 PrepU Chapter 32: Health Assessment of Children
The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first?
Inspection
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.
The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond?
"For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level."
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
A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate?
Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed.
A 15-year-old client tells the nurse about being worried that something is wrong because the left breast is bigger than the right breast. What is the best response by the nurse?
"As your breasts continue to develop it is not unusual to have one breast larger than the other."
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?
Five to 10 per minute
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 doll's blood pressure"
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 blood pressure on a child beginning at age 2 years."
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."
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 teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?
"You should auscultate all four quadrants for a full minute each."
Blood pressure monitoring becomes part of the routine health assessment at what age and older?
3 years
The nurse is assessing the apical pulse of a 4-year-old child. The nurse would place the stethoscope at which locations? Select all that apply.
4th intercostal space Midclavicular line
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 caregiver questions and document the answers.
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.
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
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 (fontanelles)
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 infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first?
Details about the fever
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 to avoid taking rectal temperatures.
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.
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
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
The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment?
Place the tape measure around the head just above the eyebrows.
The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated?
Report the findings to the physician.
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 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.
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.
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
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
During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition?
meningeal irritation
The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact?
pupil constriction in response to light
The emergency department nurse is caring for a child who is showing signs of anaphylaxis. The nurse evaluates how comprehensive the history of the child should be and determines that which action takes priority?
stabilizing the child's physical status
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?
swollen labia minora
Where is the point of maximal impulse (PMI) found in a 5-year-old child?
the fourth intercostal space
The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately?
visible peristaltic waves
