Ch 32 prepUs

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

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."

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 nurse is assessing a newborn child. The mother asks why the feet are blue. What is the best response by the nurse?

"Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body."

The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?

Ask the parents to complete a day history.

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."

As part of a class assignment a nursing student will teach fellow classmates how to conduct a physical assessment on an infant. What priority information should the student teach?

Assess the heart and lungs first.

The nurse enters a room to perform an assessment and finds the 9-month-old client asleep in the father's arms. Which action will the nurse take first?

Assess the infant's respiratory status.

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

The nurse is assessing the Babinski sign in a 3-day-old neonate. What is a normal response?

The neonate's toes fan and the big toe has dorsiflexion.

The nurse prepares to examine a 4-year-old boy. How would the nurse proceed?

Examine the child's head and work down to the child's toes.

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?

Five to 10 per minute

When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history?

"Have you heard that some teens like to smoke? Have you tried this?"

The nurse is measuring the head circumference of a 1-year-old infant during a well-child visit. The parent asks the nurse why this assessment is being performed. Which response will the nurse provide to the parent?

"Head circumference is typically assessed until age 2 or 3 to help determine if growth is appropriate."

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 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."

The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse?

"It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally."

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?

"Let's see if I can find some puppies or kittens."

The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement?

"My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."

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 explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature?

"Rectal temperatures should not be taken on a child with diarrhea."

The nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information?

"Tell me about your favorite activity at school?"

The nurse is obtaining a health history on a toddler and asks the parents about their health history, the health history of their other children, and of their parents' health history. The parents ask the nurse why this information is necessary. What is the best response by the nurse?

"The information can alert us to any disease process that might run in families."

The nurse brings a 2-day-old newborn into the mother's room in the postpartum unit. The mother voices concern that the newborn's hands and feet "look a little blue." Which response by the nurse is best?

"This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."

The nurse is obtaining health information from the parents of a 3-year-old. Which information is of most concern to the nurse?

"We are renovating an old farmhouse built in the early 1900s."

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 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."

A nurse is reviewing the physical exam of a child. The nurse notes that the child's deep tendon reflexes were normal, because they were graded as:

2+

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 a:

24-hour recall.

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

3 years

The nurse is assessing deep tendon reflexes on a child admitted for severe dehydration. The assessment reveals hyperactive reflexes. How should the nurse document this finding?

4+

The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?

A delay or lack of clear, understandable speech pattern

The nursing instructor is evaluating assessment techniques of several student nurses while performing assessments of pediatric clients. Which assessment techniques will require further instruction? Select all that apply.

A student organizes assessment equipment by laying all items, such as blood pressure cuff, stethoscope, and otoscope, on the bedside table. A student nurse awakens a sleeping infant in order to adequately assess the heart and lungs.

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.

The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?

Adolescents will share more about themselves in a private conversation.

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 nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform?

Apply water-soluble lubricant to the probe.

When preparing to examine a 2-year-old child, which action by the nurse will best establish rapport?

Bend down to the child's eye level to establish contact.

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)

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

A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

Determining the chief complaint

A 6-week-old infant is being assessed for vision acuity. What questions should the nurse ask the parents to ascertain adequate vision? Select all that apply.

Does the baby follow you with her eyes? Do the parents have any concerns? Can the baby focus on a moving object?

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

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

A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth?

Pinpoint ulcers on the gums

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.

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 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 childs physical status

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?

Take the apical pulse.

The nurse is caring for a 13 y/o girl. As a part of a routine health assessment the nurse needs to address areas relating to sexuality and substance abuse. Which statement or question should the the nurse say first to encourage communication?

Tell me about some of your current activities at school

The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement or question should the nurse say first to encourage communication?

Tell me about some of your current activities at school.

The student nurse is assessing a 9-year-old's cardiovascular system. Which assessment technique should the nurse further discuss with the student?

The student auscultates the heart at the third to fourth intercostal space just medial of the child's left midclavicular line.

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. What will the nurse need? Select all that apply.

Thermometer Stethoscope Tongue depressor Ophthalmoscope

The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct?

These lesions will normally fade as the child ages.

At a routine wellness check, the parent of a 6-month-old infant reports concerns about the infant's feet possibly being deformed. The assessment revealed the infant's feet have a mild in-toe position. What information should be provided to the infant's parent?

This finding is normal for many children; it is the result of positioning in the womb.

A 14-year-old male adolescent is brought to the clinic by his parent who is concerned the adolescent is developing an excessive amount of breast tissue. The examination confirms that the adolescent has slight enlargement of the breast tissue. What information should be relayed to the adolescent and his parent?

This is a normal and transient condition of adolescent males.

The nurse is admitting a child to the intensive care unit. The child arrives with a cardiac monitor, pulse oximeter, and an IV infusion. As the nurse begins collecting data on the child, which nursing interventions should the nurse prioritize?

Verify that the alarms on the monitor are still properly set.

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

The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment?

back and extremities; head and neck; then the ears, nose, mouth, and eyes

The nurse is assessing a child with aortic stenosis. Which findings would the nurse most likely assess? Select all that apply.

chest pain with activity dizziness with prolonged standing thrill palpated at base of heart

A nursing instructor is teaching students how to assess a newborn and emphasizes the importance of taking femoral pulses. Doing so will help to rule out which condition?

coarctation of the aorta

A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:

document as a normal finding. When assessing heart murmurs, a grading scale is used to describe the sound of the murmur. A grade I murmur can barely be heard. A grade II heart murmur is usually soft and it is easily auscultated. A grade III murmur is audible. A grade IV murmur can be heard and has an associated thrill. The grade V murmur is loud and can be heard with the edge of the stethoscope lifted off the chest. The grade VI murmur is very loud and can be heard with the stethoscope near but not touching the chest.

All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement?

just above the eyebrows through the prominent part of the occiput

When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom?

localized or generalized

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 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 preparing to perform a physical examination of a toddler. Which is the preferred location to complete the assessment?

with the child seated on the caregiver's lap