PEDs Chapt 10 Health Assessment of Children
The nurse is taking health history for a toddler in the emergency department. The child's mother informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection 6 weeks ago. What would the nurse recognize as is the patient's chief concern/complaint? a) pneumonia b) asthma c) vomiting d) UTI
vomiting Correct Explanation: The chief concern/complaint is the reason that the patient is seeking current health care and, in this case, is vomiting. The pneumonia, UTI, and asthma are part of the past medical history.
When questioning a 15-year-old about his or her health history, what would be an appropriate way for the nurse to ask about the child's drug history? a) "Have you smoked crack before?" b) "Have you smoked cigarettes?" c) "Have you heard that some teens like to smoke? Have you tried this?" d) "Have you had alcohol at parties before?"
"Have you heard that some teens like to smoke? Have you tried this?" Correct Explanation: When obtaining a health history from teens, the nurse should approach questions about sensitive subjects in a nonthreatening manner. This method may encourage the teen to not be afraid to ask questions and be more open. The other choices are all direct questions that may make the teen apprehensive or discourage them from being truthful when answering.
The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond? a) "Please sit still so I can see inside your ears." b) "May I please look inside your ears?" c) "Come, sit on this pretty, little red chair." d) "Let's see if I can find some puppies or kittens."
"Let's see if I can find some puppies or kittens." Correct Explanation: The nurse should try to gain the youngster's cooperation by playing a funny pretend game using the "puppies or kittens" to engage the child. It is more likely the preschooler would prefer to sit on a parent's lap even though a red chair was offered. Politely asking the child to sit still is respectful but not likely to gain cooperation. Asking permission to look into the child's ear is an invitation for the young preschooler to answer "no."
The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which of the following findings would warrant further investigation? a) Visible bony landmarks behind the membrane b) A gray tympanic membrane c) A mobile tympanic membrane d) A bubble behind the tympanic membrane e) A pearly pink membrane
A bubble behind the tympanic membrane Correct Explanation: A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation. The other findings are within normal limits.
A nurse is examining the skin of a 15-year-old girl. Which of the following findings should most warrant concern on the part of the nurse? a) A very dark mole with an uneven border b) A tattoo on the wrist, with no signs of inflammation c) A few acne lesions on the back d) A rash due to an allergic reaction to cosmetics
A very dark mole with an uneven border Correct Explanation: At least a few acne lesions on the face or back are usually present in an adolescent. Lesions or rashes caused by allergies to cosmetics also may be seen. If a child has a tattoo or body piercing, assess the site for inflammation to be certain an infection is not present. Look carefully for moles that are very dark, have uneven borders, or have recently changed shape as these are signs of melanoma or skin cancer.
The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take? a) Count the respiratory rate for 30 seconds. b) Place a stethoscope to count respirations. c) Count abdominal movements. d) Count after the child stops crying and is comfortable.
Count after the child stops crying and is comfortable. Correct Explanation: Respirations should be assessed when the child is resting or sitting quietly because respiratory rate changes significantly when children cry, eat, or become more active. They also breathe more rapidly when anxious or frightened. Counting respirations for a full minute assures accuracy. Infants' respirations are primarily diaphragmatic; therefore, counting abdominal movements promotes accuracy. Placing a stethoscope to count respirations tends to be seen as invasive by a toddler and will result in movement away or an increase in respirations.
Which of the following is a grade II heart murmur? a) The murmur is soft and hard to hear. b) The murmur is soft but easily heard. c) The murmur is loud with an associated thrill. d) The murmur is loud without an associated thrill.
The murmur is soft but easily heard. Correct Explanation: When assessing heart murmurs a grading scale is used to describe the sound of the murmur. A grade II heart murmur is usually soft and it is easily auscultated.
Which of the following is a grade II heart murmur? a) The murmur is soft and hard to hear b) The murmur is soft but easily heard.
The murmur is soft but easily heard. Correct Explanation: When assessing heart murmurs a grading scale is used to describe the sound of the murmur. A grade II heart murmur is usually soft and it is easily auscultated.
The nurse is obtaining a client history and asks the caregiver the reason for the child's visit to the health care setting. Which of the following best describes what the nurse is doing in this process? a) The nurse is interviewing the caregiver. b) The nurse is obtaining biographical data. c) The nurse is determining the chief complaint. d) The nurse is obtaining the health history.
The nurse is determining the chief complaint. Correct Explanation: The reason for the child's visit to the health care setting is called the chief complaint. In a well-child setting, this reason might be a routine check or immunizations, whereas an illness or other condition might be the reason in another setting.
The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response? a) The infant's toes stay in the normal position and the big toe has dorsiflexion. b) The infant's toes fan and the big toe has dorsiflexion. c) The infant's toes wiggle. d) The infant's foot moves back and forth.
• Tympanic • Axillary • Temporal Correct Explanation: Temporal, tympanic, and axillary temperatures would be appropriate on this child. Axillary temperatures are taken on newborns and on infants and children with diarrhea. Taking the temperature using the tympanic method is noninvasive and causes little disturbance to the child. Oral temperatures usually are taken only on children older than 4 to 6 years of age who are conscious and cooperative. Rectal temperatures are contraindicated in children who have had rectal surgery or who have diarrhea.
The nursing students are learning how to perform a health assessment on a pediatric patient. The nursing instructor identifies a need for further teaching when a student makes which of the following statements? a) "I should establish good rapport with the child's parents before beginning an assessment on a child." b) "I should take a temperature using an electronic thermometer beginning at age 3 years." c) "I should take blood pressure on a child beginning at age 2 years." d) "I should take blood pressure on a child beginning at age 3 years."
"I should take blood pressure on a child beginning at age 2 years." Correct Explanation: When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take temperature on a child who is 3 years.
A nurse is wrapping up a health interview with the father of a toddler. Which of the following would be the best question or statement to end the interview with? a) "Is there anything more about your daughter that we should know?" b) "Was yesterday a fairly typical day for your daughter?" c) "Before we talk about any past illnesses or happenings with your daughter, let me ask you some questions about your family as a whole." d) "I'd like to ask about different parts of your daughter's body, from her head down to her toes, just to be certain I don't miss anything."
"Is there anything more about your daughter that we should know?" Correct Explanation: A health history should close with one last open-ended question: "Is there anything more about your daughter we should know?" or "Is there anything I didn't mention you want to ask about?" A parent may have been reluctant to bring up something earlier. Asking this final question gives a parent a final opportunity to reveal a concern. The other questions should be asked in earlier sections of the health interview (day history, health and family profile, and review of systems).
Fourteen-year-old Freddy has come to his primary-care physician's office for a routine well-child visit. In reading the child's history, the nurse notes that Freddy's father suffers from alcoholism. If Freddy's mother makes the following statements, which statement would be most important for the nurse to gather further data regarding? a) "I think I know how Freddy feels about drinking. He has had substance abuse education in school." b) "Sometimes Freddy asks me questions about his father's low tolerance for alcohol." c) "Our next door neighbor is older than Freddy, and he drinks when they hang out together." d) "I wish there was a blood test for alcoholism. I know Freddy is at risk."
"Our next door neighbor is older than Freddy, and he drinks when they hang out together." Explanation: Some diseases and conditions are seen across families and are important in prevention as well as detection for the child. The caregiver can usually provide information regarding family health history. The nurse should use this information to do preventive teaching with the child and family. Early adolescence is a time when experimental use of substances, especially alcohol and tobacco, might be seen. It would be important to assess the use of substances and follow up regarding the behaviors of the adolescent.
The nurse is discussing taking a temperature on a child with a group of nursing students in a post-conference setting. Which of the following statements made by the nursing students is most accurate related to taking a temperature? a) "A rectal temperature is usually 0.5° to 1.0° lower than the oral measurement." b) "Tympanic temperatures should not be taken on a child who is sleeping." c) "Rectal temperatures should not be taken on a child with diarrhea." d) "An axillary temperature usually measures 0.5° to 1.0° higher than the oral measurement."
"Rectal temperatures should not be taken on a child with diarrhea." Correct Explanation: A rectal temperature should not be taken in the newborn because of the danger of irritation to the rectal mucosa or in children who have had rectal surgery or who have diarrhea.
A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do which of the following? a) 3-day recall b) 12-hour recall c) 24-hour recall d) 1-week recall
24-hour recall Correct Explanation: Food intake is best obtained by asking a parent to describe a typical day (24-hour recall), listing what the child ate for each meal and between meals as well.
The nurse is gathering data from the caregiver of 3-year-old Jared who was heard complaining that he was nauseated while sitting in the waiting room. In interviewing the child's caregiver, which of the following would be the most appropriate initial question for the nurse to ask the caregiver? a) "Does anyone else in the family have the same symptoms?" b) "Has Jared had anything to eat that he might be allergic to?" c) "What caused you to decide to bring Jared to the clinic today?" d) "How often does Jared complain of being nauseated?"
"What caused you to decide to bring Jared to the clinic today?" Correct Explanation: To best care for the child, it is important to get the most complete explanation of what brought the child to the health care setting. Repeating the caregiver's statement regarding the child's chief complaint would be helpful in clarifying that the nurse has correctly heard what the caregiver has said.
A nurse is interviewing a father regarding his 2-year-old daughter's recent illness. The nurse would like the father to elaborate about any symptoms of the illness that he has noticed. Which of the following would be the most effective question for the nurse to ask the father in this situation? a) "Has your daughter exhibited any symptoms?" b) "Your daughter hasn't exhibited a fever, has she?" c) "What symptoms has your daughter exhibited?" d) "Has your daughter exhibited a fever and vomiting?"
"What symptoms has your daughter exhibited?" Correct Explanation: An open-ended question, such as, "What symptoms has your daughter exhibited?" allows a parent to elaborate, which is what the nurse desires in this case. A closed-ended question, such as, "Has your daughter exhibited any symptoms?" does not allow the parent to elaborate, and thus would be inappropriate in this case. Compound questions, such as, "Has your daughter exhibited a fever and vomiting?" should be avoided because the information they elicit is often inaccurate and must be clarified. Likewise, leading questions, such as, "Your daughter hasn't exhibited a fever, has she?" should be avoided.
Which of the following assessments would you expect to introduce for the first time in the physical examination of a 3-year-old child? a) Observation of walking gait b) Blood-pressure recording c) Snellen vision testing d) Standing height measurement
Blood-pressure recording Correct Explanation: Assessing blood pressure is generally introduced at preschool age. The preschool E-chart is used for vision screening at this age.
When 12-year-old Chelsie comes in for her annual check-up, the nurse must take a health history and do a physical exam. What is the most appropriate manner for the nurse to obtain a health history? a) Ask Chelsie to fill out the health form and return it herself. b) Ask Chelsie if she minds if her mother is in the room with her. c) Ask Chelsie to wait outside while the nurse talks with her mother. d) Ask Chelsie's mom to leave the room.
Ask Chelsie if she minds if her mother is in the room with her. Correct Explanation: Cultural and spiritual dynamics are important in taking a health history. This age of child likes choices and is concerned about modesty and privacy. For pre-adolescents, letting children choose whether or not a parent is with them in the exam room and during the history is appropriate. In either event, it is important to speak with the adolescent alone at some point. Asking Chelsie to wait outside does not acknowledge her as a person. Asking Chelsie's mom to leave the room does not give Chelsie a choice in her care. Asking Chelsie to fill the form out herself is not supportive, and does not facilitate an exploration of her history.
The nurse is examining the testicles of a 6-year-old boy. How can the nurse prevent a retractile testis from slipping back up the inguinal canal? a) Ask the boy to stand. b) Ask the boy to sit cross-legged. c) Apply gentle pressure on the inguinal canal. d) Place one finger over the inguinal canal.
Ask the boy to sit cross-legged. Correct Explanation: For a 6-year-old boy, sitting cross-legged reduces the cremasteric reflex that retracts the testicles during palpation. Having a boy stand is best for an adolescent. Placing a finger over the inguinal canal or applying gentle pressure would be best for an infant.
The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. Which of the following is the most appropriate way to gather information from the child's caregiver? a) Ask the caregiver if they can read or if they need someone to read the questions on the admission form to them. b) Ask the caregiver questions and write the answers down. c) Have the caregiver sit in a quiet room and fill out a questionnaire. d) Have the child read the questions to the caregiver and then write down the answers on the form.
Ask the caregiver questions and write the answers down. Correct Explanation: The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler. Rather than simply asking the caregiver to fill out a form, it may be helpful to ask the questions and write down the answers. (less)
A nurse is performing a physical examination on a newborn. Which of the following assessments should she include? a) Temporal temperature, blood pressure, reflexes b) Oral temperature, blood pressure, head circumference c) Axillary temperature, femoral pulse, head circumference d) Rectal temperature, femoral pulse, head circumference
Axillary temperature, femoral pulse, head circumference Correct Explanation: When examining newborns, take axillary or temporal temperatures to prevent rupture of rectal mucosa. Be certain to take femoral pulses in newborns to rule out coarctation of the aorta. Include newborn reflexes, head circumference, and an assessment of gestational age as routine parts of the examination. Taking blood pressure is not necessary because this value is unreliable in newborns.
The nurse is taking an apical pulse on an infant. The nurse should place the stethoscope at which of the following sites? a) Above the clavicle on the left side b) Between the sternum and the left nipple c) Above the sternum, slightly to the right d) Below the ribs about one half of an inch
Between the sternum and the left nipple Correct Explanation: When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum.
While interviewing a mother about her infant son's illness, the nurse asks, "Why did you bring Clark to the clinic today, Ms. Donovan?" Which part of the health interview is this nurse currently in? a) Day history b) Chief concern/complaint c) Demographic data d) Health and family profile
Chief concern/complaint Correct Explanation: The first topic parents want to talk about is the reason they have brought the child to the health care agency on the day, or the chief concern/complaint. An effective way to elicit this information is to ask directly, "Why did you bring Clark to the clinic today, Ms. Donovan?" Demographic data refers to data such as a child's name, address, gender, social security number, and the name of the person who will be providing information. A family profile includes documentation of the circumstances in which the child lives. The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day (day history).
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find? a) Open anterior fontanel and closed posterior fontanel b) Closed anterior fontanel and open posterior fontanel c) Closed anterior and posterior fontanels d) Open anterior and posterior fontanels
Closed anterior and posterior fontanels Correct Explanation: By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
The nurse is caring for a child who is on a cardiac monitor. Which of the following nursing actions would be the most important action for the nurse? a) Clean the skin with alcohol before placing the electrodes. b) Check to be sure that the electrodes are secure when the alarm sounds. c) Confirm the alarms are set with maximum and minimum settings. d) Check the site and skin condition every couple of hours.
Confirm the alarms are set with maximum and minimum settings. Correct Explanation: Cardiac monitors are used to detect changes in cardiac function. The highest priority would be to ensure the alarms are set with maximum and minimum settings and that the alarm is turned on. Many of these monitors have a visual display of the cardiac actions. Electrodes must be placed properly to obtain accurate readings of the cardiac system. The skin is cleaned to remove dirt, lotions, and powder before the electrodes are applied. The electrode sites must be checked every two hours to detect any skin redness or irritation and to determine that the electrodes are secure.
The nurse is conducting the Denver articulation screening examination (DASE) with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam? a) Have the child read each of the 22 words from a sheet of paper b) Convey the impression that there are no right or wrong answers c) Modify the directions of the test using the nurse's own discretion d) At the end explain which words the child missed and why
Convey the impression that there are no right or wrong answers Correct Explanation: The DASE is designed to detect significant developmental delays as well as normal variations in the acquisition of speech sounds. Because it is a standardized test, its directions must be followed precisely, not modified according to the nurse's own discretion. Before the test, explain the child will need to repeat the words she hears you speak. Give enough examples you are certain she understands what she is to do: "When I say 'boat,' then you say 'boat.'" When you are certain the child understands the directions, say each of the 22 words shown on the DASE form; do not have the child read the words from a sheet of paper. Convey the impression that there are no right or wrong answers. Give the child approval for responding and following directions correctly, no matter how inaccurately the child repeats the word; the nurse should not explain which words the child missed and why.
A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first? a) Family profile b) Details about the fever c) Review of systems d) History of past illnesses
Details about the fever Correct Explanation: Health interviews typically begin with a history of the chief complaint, because this is what people want to talk about first and represents a primary health problem.
Anna is 4 years old and complains of ear pain. To examine Anna's ear, how should the nurse proceed? a) Grasp the pinna and pull down and back. b) Grasp the pinna and pull forward. c) Grasp the pinna and look inside. d) Grasp the pinna and pull up and back.
Grasp the pinna and pull up and back. Correct Explanation: The ear is examined in a child younger than 3 years of age by pulling the pinna down and back. In a child over 3 years old, the ear is examined by pulling the pinna up and back. These maneuvers straighten the ear canal so that the tympanic membrane can be visualized.
A nurse is conducting a physical examination on a 5-year-old boy and is examining his abdomen. First she visually inspects the region. Then she auscultates it with a stethoscope. Finally, she palpates the area. What is the proper rationale for performing the auscultation before palpation? a) Handling the abdomen may obliterate bowel sounds b) The order does not matter; she could have performed palpation before auscultation c) If she detects no abnormalities in auscultation, there will be no need for palpation d) Auscultation is scary for small children and should thus be performed first, to get it over with
Handling the abdomen may obliterate bowel sounds Correct Explanation: Unlike in other regions, in the abdomen auscultation should follow inspection and precede palpation of the abdomen because handling the abdomen may obliterate bowel sounds. Not detecting abnormalities on auscultation does not eliminate the need for palpation. Auscultation is not necessarily scary for small children.
The nurse is taking a family history of a 10-year-old with asthma. What would be a helpful tool to obtain a family history of illness and disease? a) Have the family write down any history they remember. b) Have the family fill out a health questionnaire. c) Make a family tree for tracking purposes. d) Help the family design a genogram.
Help the family design a genogram. Correct Explanation: A genogram diagram shows the relationship between family illnesses and diseases in a visual manner. The other choices put the history responsibility on the patient and family and do not show a relationship among illnesses.
Which of the following should a nurse include in her pediatric history of 8-year-old patient Rosie? a) How many friends Rosie has b) Where Rosie lives c) Immunizations d) Her favorite toys
Immunizations Correct Explanation: Immunizations should be included in a pediatric history. This tells whether Rosie is up to date according to standard recommendations. This also shows the health promotion that Rosie is involved in. The other choices are part of Rosie's life but not critical factors.
Nurse Betty is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? a) In the nurse's own arms b) In the child treatment room c) In the crib facing the mom d) In the crib on the infant's back
In the crib facing the mom Explanation: When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view.
Which technique would you begin with to assess a child's abdomen? a) Percussion b) Inspection c) Auscultation d) Palpation
Inspection Correct Explanation: Inspection is typically the first assessment technique used.
Below are the first six (of nine total) sections of an initial health assessment interview. Put them in the correct order: Introduction and explanation History of chief concern/complaint Chief concern/complaint Demographic data Day history Health and family profile
Introduction and explanation Demographic data Chief concern/complaint History of chief concern/complaint Health and family profile Day history Correct Explanation: Data gathering for an initial health assessment can be divided into nine sections in the following order: 1) introduction and explanation; 2) demographic data; 3) chief concern; 4) history of chief concern; 5) health and family profile; 6) day history; 7) past health history, including pregnancy history; 8) family health history; 9) review of systems.
Nurse Julie is doing a physical exam on a 3-year-old boy. What method would Julie use to perform the exam? a) Julie would examine the child's extremities first and then the chest. b) Julie would examine the child's chest and then go to the head and down. c) Julie would examine the child's head and work down to the child's toes. d) Julie would examine different sections of the body at various times.
Julie would examine the child's head and work down to the child's toes. Correct Explanation: A preschool or toddler child should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants, the examination starts with the chest, and then proceeds from head to 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 for? a) Startle b) Moro c) Palmar grasp d) Babinski
Moro Correct Explanation: The moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs. This response should not persist after 4 months of age. The Babinski reflex is tested through stimulating the foot/toes, the palmar reflex through the hand/fingers, and the startle reflex through loud noises (e.g., clapping).
The nurse is measuring the head circumference of a child. Which of the following is accurate related to this procedure? a) Place the tape measure around the head just above the eyebrows. b) Place the tape measure around the head with the tape touching just below the eyes. c) Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. d) Measure the head circumference routinely on children up to the age of 6 years.
Place the tape measure around the head just above the eyebrows. Correct Explanation: The head circumference is measured routinely in children to the age of 2 or 3 years or in any child with a neurologic concern. Place a paper or plastic tape measure around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head. During childhood the chest exceeds the head circumference by 2 to 3 inches.
The nurse is assessing the growth of a premature infant. What would be the appropriate action by the nurse to complete this assessment? a) Take vital signs. b) Weigh the infant's diapers. c) Plot the infant's weight, height, and length on a growth chart. d) Ask mom if her baby eats enough.
Plot the infant's weight, height, and length on a growth chart. Correct Explanation: The assessment for growth for a premature infant entails plotting his or her weight, length, and height on a growth chart, which is then analyzed. If the infant is below the growth curve, they are not growing appropriately and interventions may be needed. The nurse weighing the diapers is checking the intake and output of the infant, as does asking mom if the infant eats enough. Taking vital signs does not relate to growth.
A nursing student asks the nursing instructor to explain pulse oximetry measurements in child. The nurse is accurate in telling the student which of the following? a) Pulse oximetry measures the oxygen saturation of arterial hemoglobin. b) If the oximeter probe is to be left in place, the site should be checked every eight hours. c) Pulse oximetry is done to detect respiratory retractions in the child. d) Place the probe of the oximeter on the child's chest and secure it with tape.
Pulse oximetry measures the oxygen saturation of arterial hemoglobin. Correct Explanation: Pulse oximetry measures the oxygen saturation of arterial hemoglobin. The probe of the oximetry unit can be placed on the finger, toe, or clipped on the earlobe. In an infant, the foot or toe is often used. In certain situations the probe is left in place to continually monitor the oxygen saturation. Check the site every two hours to ensure that the probe is secure and tissue perfusion is adequate. Change the site at least every four hours to prevent skin irritation.
The nurse is performing an examination of the eyes of a 7-year-old girl. Which of the following findings would indicate that the third cranial nerve is intact? a) Pupil constriction in response to light b) Light of an otoscope reflecting evenly off both pupils c) Pupil dilation in response to light d) The eyelid blinks in response to touching the cornea with a wisp of cotton
Pupil constriction in response to light Correct Explanation: If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment.
When doing a health assessment on a child, the nurse should include a physical assessment. What is the most important thing to assess first when performing the physical assessment? a) Temperature b) Lung sounds c) Respirations d) Blood pressure
Respirations Correct Explanation: The assessment of respirations should always be done first. Completing other parts of the physical assessment could influence the count of respirations.
Where is the PMI found in Lucy who is 5 years old? a) The PMI is at the fourth intercostal space. b) The PMI is at the clavicle. c) The PMI is at the sternum. d) The PMI is at the third intercostal space.
The PMI is at the fourth intercostal space. Correct Explanation: The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. In children younger than 7 it occurs at the fourth intercostal space.
The nurse is auscultating the heart of a 6-month-old. Which of the following findings would warrant further investigation? a) Heart rate of 120 b) Variation in heart rate during the 60 second auscultation c) S1 varies in intensity.
S1 varies in intensity. Correct Explanation: The S1 should not vary in intensity at a particular point. If it does, this may indicate a cardiac arrhythmia, and the child should be referred for further evaluation. A split S2 at the apex occurs in many infants and young children. The other findings are within the normal range for a child of 6 months.
The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? a) Petechiae b) Purpura c) Salmon nevus d) Nevus flammeus
Salmon nevus Correct Explanation: A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.
Assessing skin in children is an important factor and good indicator of their overall condition. Which of the following describes cyanosis of the skin? a) Skin that is bluish b) Skin that is an olive-tone c) Skin that is yellowish d) Skin that is pink
Skin that is bluish Correct Explanation: Cyanosis is a condition where there is decreased hemoglobin in the blood. This decrease in oxygen gives the skin a bluish tone. It usually involves the lips, mouth, and trunk.
A nurse conducted a health history with a 5 year old admitted with abdominal pain. The nurse stood at the bedside while talking to the mother and child. The patient was in a private room. The nurse made sure the door was closed and referred to the mother as "Mrs. Smith" whenever asking a question. Which of the following actions by the nurse was not conducive to the health history? a) Conducting it in a private room b) Referring to the mother as Mrs. Smith c) Closing the door d) Standing at the bedside
Standing at the bedside Correct Explanation: An interview is best conducted in a private room with all parties seated. If not, then the health care worker appears rushed and cannot interact at eye level. The nurse should call the parent by his or her name, because doing so lets the party know his or her input and opinions about how the child is developing are valued.
When performing a physical examination on a child, if there is a mirror image in shape, size, and position from one side of the body to the other, the child would have which of the following? a) Symmetry b) Accommodation c) Alignment d) Retraction
Symmetry Correct Explanation: The mirror image in shape, size, and position from one side of the body to the other is known as symmetry.
To obtain an accurate heart rate in an infant, which of the following would be the most important for the nurse to do? a) Use a regular stethoscope. b) Take the apical pulse. c) Check when infant is quiet. d) Count the pulse rate for 30 seconds.
Take the apical pulse. Correct Explanation: Taking the apical pulse with a pediatric stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant.
The nurse is interviewing an adolescent. Which of the following should the nurse recognize as an important aspect of interviewing the adolescent? a) The adolescent will talk more openly if their caregivers are in the same room. b) The adolescent will not likely share information related to sexual relationships or to use of substances. c) The adolescent should be asked if they would like a peer in the room during the interview. d) The adolescent will share more about themselves in a private conversation.
The adolescent will share more about themselves in a private conversation. Correct Explanation: Adolescents can provide information about themselves. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers.
When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history? a) History of illness b) The chief complaint of the child c) How the child feels school is going d) Types of medications the child is on
The chief complaint of the child Correct Explanation: The next step in the health assessment is the reason for seeking treatment. Remember to include the child's reason because it may be different from that of the parent or caretaker.
The nurse is examining the heart and peripheral perfusion of an 8-year-old. The nurse will assess the apical impulse at which location? a) The fourth intercostal space just medial to the child's left midclavicular line b) The fifth intercostal space lateral to the left midclavicular line c) The fourth intercostal space at the left midclavicular line d) The fifth intercostal space medial to the left midclavicular line
The fifth intercostal space lateral to the left midclavicular line Correct Explanation: The apical pulse can be found at the fifth intercostal space lateral to the left midclavicular line in children over 7 years. The apical pulse's point of maximal intensity is at the fourth intercostal space just medial to the child's left midclavicular line until age 4 years and at the fourth intercostal space at the left midclavicular line from ages 4 to 6 years. The fifth intercostal space medial to the left midclavicular line incorrectly locates the apical pulse medially rather than laterally for someone over 7 years.
The nurse is assessing the Babinski sign in a 3-day-old infant. What is a normal response? a) The infant's toes fan and the big toe has dorsiflexion. b) The infant's toes stay the way they are and the big toe has dorsiflexion. c) The infant's toes wiggle d) The infant's toes do not move.
The infant's toes fan and the big toe has dorsiflexion. Correct Explanation: When assessing the Babinski sign, the infant's foot is stroked on the lateral side. The normal response is for the toes to fan out and the big toe to dorsiflex. This sign is abnormal after 24 months of age.
The nurse is collecting subjective data when doing which of the following? a) The nurse is reinforcing teaching with the child's caregivers. b) The nurse is taking the child's vital signs. c) The nurse is interviewing the child's caregiver. d) The nurse is weighing and measuring the child.
The nurse is interviewing the child's caregiver. Correct Explanation: Information spoken by the child or family is called subjective data. Interviewing the family caregiver and child allows you to collect information that can be used to develop a plan of care for the child.
The nurse is weighing an 18-month-old infant who is in the clinic for a well-child visit. Which of the following actions by the nurse would be most appropriate for weighing this child? a) The nurse should lay the infant on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. b) The nurse should weigh the mother on a standing scale and then weigh her again while the mother is holding the infant. c) The nurse should ask the mother to lightly hold the infant's hands while the infant is sitting on the scale. d) The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. Correct Explanation: The toddler who is able to sit can be weighed while sitting. Keep a hand within 1 inch of the child at all times to be ready to protect the child from injury.
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? a) The reflex is hyperactive. b) The reflex is brisk. c) The reflex is diminished. d) The reflex is absent.
The reflex is diminished. Correct Explanation: On the four-point grading scale used in assessing deep tendon reflexes, 1+ indicates a diminished response. With 2+ as average, a grade of 3+ is brisker than average and 4+ is hyperactive. The reflex is absent at a grade of 0.
Where would the S2 "dub" sound be the loudest? a) The third intercostal space b) The second intercostal space c) The fifth intercostal space d) The fourth intercostal space
The second intercostal space Explanation: The aortic area is auscultated in the second intercostal space. Here the S2 sound is louder than S1 and is a "dub" sound.
The mother of 2-year-old triplets is anxious and worried because one of the children, Emily, does not seem to be at the same developmental level as her siblings. If the following findings were found when doing a physical exam, which finding might indicate a need for further diagnostic testing to rule out intellectual disability in this child? a) She speaks loudly when asked a question. b) The fontanels on her head are closed. c) She blows her nose frequently. d) The tops of her ears are below the corners of her eyes.
The tops of her ears are below the corners of her eyes. Correct Explanation: The alignment of the ears is noted by drawing an imaginary line from the outside corner of the eye to the prominent part of the child's skull; the top of the ear, known as the pinna, should cross this line. Ears that are set low often indicate intellectual disability. Flaring of the nostrils might indicate respiratory distress and should be reported immediately. A child who speaks loudly, responds inappropriately, or does not speak clearly may have hearing difficulties that should be explored. It would be normal for the fontanels to be closed by this age. A child who is developing normally should be able to control her head's range of motion; any stiffness in the neck should be reported immediately.
Anthropometric measurements help determine what about a child? a) These tell how well a child sleeps. b) These tell how what grade a child should be in. c) These tell how well a child grows. d) These tell how fast a child can run.
These tell how well a child grows. Correct Explanation: Anthropometric measurements include height, weight, and age and can help determine the child's pattern of growth.
The purpose of performing a pulse oximetry measurement when taking the vital signs on a child is which of the following? a) To measure the respiratory rate b) To measure the blood pressure c) To measure the oxygen saturation d) To measure the apical pulse
To measure the oxygen saturation Correct Explanation: Pulse oximetry measures the oxygen saturation of arterial hemoglobin.
The human papillomavirus (HPV) is associated with the development of cervical cancer in women. a) True b) False
True Correct Explanation: It is recommended all preteens (male and female) receive three injections of this vaccine beginning at 11 to 12 years of age.
The nurse is doing an assessment of a 10-year-old girl. She whispers the girl's name from behind the girl. Which cranial nerve is the nurse assessing for? a) III b) VIII c) V d) IV
VIII Correct Explanation: Testing a child's hearing by observing a response to a whisper without a visual clue, assesses cranial nerve VIII, the acoustic nerve. Nerve V is the trigeminal, nerve IV is the trochlear, and nerve III is the oculomotor, none of which are involved in hearing.
A child on a cardiac monitor has been transported from the emergency room to the intensive care unit. The nurse admits the child to the unit and begins collecting data on the child. Which of the following nursing interventions would the nurse do first? a) Assess the neurological function using the Glasgow coma scale. b) Change the probe on the pulse oximeter. c) Verify that the alarms on the monitor are still properly set. d) Check the apical pulse rate using a pediatric stethoscope.
Verify that the alarms on the monitor are still properly set. Explanation: At the beginning of each shift and after transport of the patient, the nurse must check that alarms are accurately set and have not been inadvertently changed. This is true for all types of monitors. The neurological status will most likely be checked, as well as the apical pulse, but they are not priorities. The probe on the pulse oximeter is changed if needed, but not routinely and not as a priority.
The nurse is assessing the abdomen of a 3-year-old. Which of the following findings should be reported immediately? a) Rounded abdomen b) Tympany over the abdomen c) Visible peristaltic waves d) Active bowel sounds
Visible peristaltic waves Correct Explanation: Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age.
When is the best time for the nurse to count 9-month-old Brad's respirations? a) When Brad is quiet in his mother's lap b) When Brad is laughing c) When Brad is in the playroom d) When Brad is crying
When Brad is quiet in his mother's lap Correct Explanation: The best time to count a child's respirations is when the child is quiet and calm. Having Brad on his mom's lap will keep him quiet and supported. During the other choices of scenarios, Brad is active and the count could give an inaccurate assessment.
As Julie performs her head-to-toe assessment on a 2-year-old child, when would she examine the child's ears? a) When Julie is finished examining the entire head and face b) When Julie is examining the head and face c) When Julie is first starting so as to get it over with d) When Julie is done with all of the exam in case the child gets upset
When Julie is done with all of the exam in case the child gets upset Correct Explanation: The nurse should do any type of intrusive examination, such as of the mouth or ears, at the end of the physical exam so as not to distress the child. The other choices all could cause distress to the child before or during the exam.
All infants should have their head circumference measured at health-assessment visits. This measurement is made from a) the middle of the forehead through the parietal prominences. b) the center of the forehead to the base of the occiput. c) just above the eyebrows through the prominent part of the occiput. d) the hairline in front to the hairline in back.
just above the eyebrows through the prominent part of the occiput. Correct Explanation: Measuring heads consistently from above the eyebrows to the occiput allows measurements at different visits to be compared.
When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom? a) color b) amount c) localized or generalized d) quality
localized or generalized Correct Explanation: When assessing symptoms such as pain, rashes, or lesions, the location must be assessed for local or generalized. Pain should also be assessed for deep, superficial, or radiating. The other choices describe the quality and quantity of the symptom.
A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. Which of the following will she need? (Select all that apply.) a) Syringe b) Ophthalmoscope c) Tongue depressor d) IV bag e) Thermometer f) Stethoscope
• Ophthalmoscope • Tongue depressor • Thermometer • Stethoscope Correct Explanation: When performing a complete physical assessment, you'll need the following equipment: a thermometer, a stethoscope, a tongue depressor, an ophthalmoscope, an otoscope, a sphygmomanometer, a tape measure, a tuning fork, a reflex (percussion) hammer, examination gloves, and perhaps a client drape or gown. A syringe or IV bag would not be needed.
While examining a child, the nurse notes quiet, soft sounds each time the stethoscope is moved over the child's chest. The nurse knows that these are not breath sounds. The nurse will: (Select all that apply.) a) Conclude this is a grade 3 heart murmur. b) Refer the child for further evaluation. c) Record the location and timing of the sounds. d) Auscultate with the child lying down. e) Auscultate with the child sitting up.
• Refer the child for further evaluation. • Record the location and timing of the sounds. • Auscultate with the child lying down. • Auscultate with the child sitting up. Correct Explanation: The sounds described are characteristic of a grade 2 heart murmur. The child's heart should be auscultated with the child in two different positions—upright and reclining. Innocent murmurs often disappear when the child's position is changed. Recording the location and timing of the sounds is important to further evaluation and in determining the type and meaning of the murmur. A child with a heart murmur needs further evaluation by an experienced examiner.
The nurse is taking vital signs on a 6-month-old infant. The caregiver reports that over the past 12 hours, the child has had vomiting, diarrhea, and has been pulling on his ears. Which of the following methods would be appropriate for taking this child's temperature? Select all that apply. a) Rectal b) Tympanic c) Oral d) Axillary e) Temporal
• Temporal • Tympanic • Axillary Explanation: Temporal, tympanic, and axillary temperatures would be appropriate on this child. Axillary temperatures are taken on newborns and on infants and children with diarrhea. Taking the temperature using the tympanic method is noninvasive and causes little disturbance to the child. Oral temperatures usually are taken only on children older than 4 to 6 years of age who are conscious and cooperative. Rectal temperatures are contraindicated in children who have had rectal surgery or who have diarrhea.
