unit1 prep u notes ch32

A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database?

Immunization record

While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nusre most likely be performing?

Assessing vision Hearing and vision screenings are examples of secondary prevention in health assessments. These are usually state or mandated screenings to prevent risk factors of specific diseases.

A nursing instructor is teaching about taking a health history and how to elicit a chief concern. The instructor realizes a need for further education when a student makes with statement?

Frequency refers to how often the concern occurs during the day. Intensity refers to the kind of problem. Associated symptoms are important to ask about.

When obtaining information from a teen concerning the reason for seeking health care, which question would be most important?

"What health concerns are you having?"

The health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer?

1/4 to 1/2 inch (0.64 to 1.27 cm)

The nurse is measuring the head circumference of a newborn during a well-child visit. Until which age should the nurse take this measurement?

24 months

A nurse is assessing a 3-year-old child in the local health clinic. The child has a persistent cough on examination. Based on the age of the child, which muscle would the nurse view to assess respiratory status?

Abdominal muscle Infants and children younger than age 6 years typically use their abdominal and diaphragm muscles for breathing.

The nurse is examining a child and asks the child to show all of the teeth. For which cranial nerve would the nurse be testing?

Blood pressure monitoring becomes part of the routine health assessment at what age?

The nurse is reviewing vital signs taken by the unlicensed assistive personnel on a group of toddlers. Which warrants follow up by the nurse?

Heart rate 60, respiratory rate 31 the toddler the heart rate may range from 70 to 120 beats per minute. The respiratory rate may range from 20 to 30 per minute.

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?

Closed anterior and posterior fontanels

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 preparing to perform an assessment on a child who has recently been diagnosed with a chronic disease. The previous shift nurse reports that the father of the child is not dealing well with the diagnosis and appears to be in the anger phase response to illness. What actions should the nurse take to ensure safety? Select all that apply.

Sit close to the doorway when talking with the child and father. Ask another nurse to assist with the assessment. Approach the child and father in a calm manner, showing empathy for the situation.

The nurse is taking the health history of a 15-year-old client. What would be an appropriate way for the nurse to ask about the client's drug use history?

Some teens like to smoke. Have you tried this?

53s Due to casts on both arms, the nurse must measure an 11-year-old client's blood pressure in the thigh. After placing the blood pressure cuff on the thigh, which action by the nurse demonstrates understanding of the procedure?

The nurse places the stethoscope over the popliteal artery

The experienced nurse is assessing the child's lungs. Rank the following steps in the proper order of assessment.

The nurse visually inspects the child's thorax. The nurse palpates the child's thorax. The nurse percusses over the child's lungs. The nurse auscultates the child's lungs.

A nurse is interviewing a parent regarding the 2-year-old child's recent illness. The nurse would like the parent to elaborate about any symptoms of the illness noticed. Which would be the most effective question for the nurse to ask the parent in this situation?

What symptoms has your child exhibited?

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:

When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The reccomendations are that blood pressure assessment be done at least once during every health care visit on children aged 3 years and older. Children younger than 3 years should have blood pressure assessed if they have a history of prematurity, have congential heart defect, have a urinary tract infection, take any medications that influence the blood pressure or have increase intracranial pressure. Blood pressure measurement on hospitalized children is taken according to hospital policy no matter what age. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years.

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

A nurse is assessing an infant's reflexes. The nurse places his or her thumb to the ball of the infant's foot to elicit which reflex?

plantar grasp

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