CHAPTER 31 ASSESSING CHILDREN AND ADOLESCENTS

The school nurse is assessing vision and hearing for several kindergarteners. At what age does visual acuity approximate that of the adult? 3 to 4 1 to 2 5 to 6 7 to 8

5 to 6

The nurse is caring for an 11-year-old child who was hospitalized after an auto accident. While communicating with this child, the nurse should allow the child to engage in the discussions. use simple questions. provide simple explanations. use peers as examples.

Allow the child to engage in the discussion

A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action? Apply oxygen via nasal cannula Provide reassurance to calm the child Transport the child for chest x-ray Encourage prolonged exhalation by having child blow up a balloon

Apply oxygen via nasal cannula

The nurse documents that an adolescent female is in Tanner's stage 4 of pubic hair. What did the nurse most likely assess in this client? Adult pattern of inverse triangle with growth on the medial thighs Dark, curly, and abundant on mons pubis with no growth on medial thighs Sparse, long, straight downy hair Darker, coarse, curly but sparse over the mons pubis

Dark, curly, and abundant on mons pubis with no growth on medial thighs

A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding? Percuss to assess for a consolidation Report the finding to the health care provider Document the finding in the child's chart Auscultate lungs for adventitious sounds

Document the finding in the child's chart

The nurse is doing an initial assessment on a school age client admitted to the pediatric unit in sickle cell crisis. When inspecting the eyes, the nurse finds that they are normal. How would the nurse chart these findings? Eyes are PERRLA with EOMs at 180 degrees bilaterally Eyes are WNL Eyes are PERRLA with corneal light reflexes equal bilaterally Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal

Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal

Upon inspection of the external eyes of a child, which position should indicate to the nurse that the eyes are properly located? Outer canthus aligns with the tip of the pinna Eyebrows are symmetrical in shape over the eyes Epicanthal folds partially cover the inner canthus Corneal reflex is in the same location in both eyes

Outer canthus aligns with the tip of the pinna

A nurse is assessing the feet and legs of a child with Down's syndrome. Which of the following findings should the nurse expect in this client? Select all that apply. Palmar simian crease Hyperextensible joints Adduction of the forefoot and inversion of the entire foot Short, broad extremities Inward positioning of the forefoot, with the heel in normal straight position Twisting of the tibia inward on its long axis

Palmar simian crease Hyperextensible joints Short, broad extremities

The nurse is conducting a health history with an adolescent patient. What should the nurse explain to the patient about confidentiality? "Everything that is discussed will be kept confidential." "Since you are a minor, your health history is to be shared with your parents." "The only thing that I must share is information that concerns your safety." "The only thing that I can share with your parents is if you are sexually active."

The only thing that I must share is information that concerns your safety.

What care should a nurse take to encourage the adolescent to communicate during the health assessment interview? Conduct interview in the presence of client's parents Remain silent and allow the client to talk Use open-ended and specific questions Maintain a friendly approach

Use open-ended and specific questions

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect? Mastitis Trauma Gynecomastia Precocious puberty

mastitis

The nurse is assessing a 4-year-old child with a temperature of 37.7 °C (100 °F). The nurse observes that the client has Koplik spots on his buccal mucosa. The nurse should explain to the client's parents that the child is most likely exhibiting signs of mumps. chickenpox. tonsillitis. measles.

measles

Which assessment finding is commonly observed in clients diagnosed with streptococcal pharyngitis (strep throat)? red, distorted tympanic membrane petechiae on the roof of the mouth discoloration of the teeth thrush noted in the oral cavity

petechiae on the roof of the mouth

After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be stage 1 stage 4 stage 2 stage 3

stage 2

The nurse is assessing a young adolescent female client using Tanner Sexual Maturity Rating for Breast Development. The nurse determines that the client has enlargement of the breasts and areolae, with no separation of contours. The client is in Tanner Stage five. three. four. two.

three.