Chapter 10: Health Assessment of Children

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 mother of a 2-month-old child reports her baby "breathes fast." When questioned further, the child's mother states she has counted the times using her watch and it was sometimes as high as 30 breaths per minute. What is the best response by the nurse?

"Babies breathe rapidly and the amount you are reporting is within normal limits."

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."

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 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 parents of a 3-week-old infant question the presence of light pink "spots" on the back of their infant's neck. The nurse checks the areas and recognizes they are salmon nevi. What response by the nurse is most appropriate?

"These will gradually fade but may not go away."

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?"

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+

The student nurse is caring for a child who weighs 48 pounds and is 38 inches tall. Which is the child's body mass index (BMI)?

23

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

A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?

96.6°F (35.8°C)

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

A nurse is examining the skin of a 15-year-old girl. Which finding would most warrant concern on the part of the nurse?

A very dark mole with an uneven border

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

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.

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.

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 preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client?

Blood pressure recording

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 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?

Count after the child stops crying and is comfortable.

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

A 4-year-old child is brought to the clinic by the parent, who reports the child is experiencing ear pain. How would the nurse most likely examine the child's ears?

Grasp the pinna and pull up and back.

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.

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

Five to 10 per minute

A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading?

Have you kept the child up to date on all of the immunizations suggested?

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 full-term gestation infant weighed 8 pounds 1 ounce (3700 g) at birth. The baby's weight at the 4-month-old well-child visit is 10 pounds 2 ounces (5000 g). Which intervention should the nurse implement first?

Notify the healthcare provider of the findings.

The nurse is conducting a physical examination of a healthy 6-year-old. Which action should the nurse do first?

Observe the skin for its overall color and characteristics.

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 nurse is preparing to measure an infant's temperature with a tympanic thermometer. Which is the correct way to position the device?

Pull the child's earlobe back and down and point the sensor beam toward the center of the tympanic membrane.

When assessing the eyes of a toddler, the nurse notes the sclera shows above the pupil. Based on this finding what action should the nurse take?

Report the finding to the health care provider.

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

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.

The nurse is assessing a child's heart sounds for the characteristic S1 and S2. Where would the nurse place the stethoscope to hear S2 "dub" sound the loudest?

The second intercostal space

The nurse collects a client history including biographical data regarding the child being admitted. Which responsibility is most important related to the data collected?

This information is part of the legal record and should be treated as confidential.

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

The nurse is conducting a physical examination of a 10-year-old child. The nurse whispers the child's name from behind the child so that the child does not see the nurse's lips moving. Which cranial nerve is the nurse assessing?

VIII

During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition?

meningeal irritation

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 examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include? Select all that apply.

color location size distribution

The nurse is assessing eye alignment in a 6-year-old child. Which assessment method is most appropriate?

covering one eye and then removing the cover

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?

cranial nerve VII

The nurse is performing an assessment on a teen's clavicle strength. The teen is asked to shrug and raise the shoulders while the nurse applies gentle pressure to them. When documenting the findings, this should be identified as an assessment of which cranial nerve?

cranial nerve XI

A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction?

down and back

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

A new client arrives for a first visit to the pediatric clinic. The nurse will prioritize which step in this appointment?

obtaining biographical data

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

A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe?

redness of the cheeks and lips

A nurse is conducting the health history of a 5-year-old child. Which data would the nurse collect last?

review of systems

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