Chapter 34: Child Health Assessment

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? A. Details about the fever B. Family profile C. History of past illnesses D. Review of systems

A

All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? A. just above the eyebrows through the prominent part of the occiput B. the center of the forehead to the base of the occiput C. the hairline in front to the hairline in back D. the middle of the forehead through the parietal prominences

A

During a previous well-child visit, the nurse reviews the importance of immunizations for the preschool-age child with the parents. Which outcome indicates that the nurse's instruction to the parents has been effective? A. Child has all immunizations up-to-date. B. Parents plan to have the child receive needed immunizations within a year. C. Child began to cry during an immunization, and the decision was made totry again later. D. Primary care physician changed the appointment for immunizations to another day in a month.

A

The nurse administers a Denver Developmental Screening Test to a preschool- age child. Which statement is the best introduction to this test for her mother? A. "This test will identify different developmental skills your child can perform." B. "It will be best if you do not watch your child during the test." C. "The test will be important in determining your child's future IQ level." D. "The test may be inaccurate because it is not well standardized."

A

The nurse is preparing to assess a school-age child who is experiencing pain in the left femur area. When conducting this assessment, at which point should the nurse assess the painful region? A. last B. first C. after measuring vital signs D. before the abdominal assessment

A

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education? A. "You should auscultate all four quadrants for a full minute each." B. "Hypoactive bowel sounds are expected in a client with diarrhea." C. "Bowel sounds should be present within the first few days of life." D. "Bowel sounds will be audible by the naked ear unless distention is present."

A

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? A. Ask the parents to complete a day history. B. Ask the parents to name the games the child knows. C. Ask the child how much time the mother is with the child. D. Ask the parents how many hours are spent playing with the child each day.

A

Which statement best explains the principle behind a Rinne test for determining hearing loss? A. Air conduction of sound is normally better than bone conduction of sound. B. Conduction of sound is intensified in the middle of the forehead. C. A tuning-fork vibration will not be heard as sound in a child under 2 years of age. D. Bone conduction of sound is normally better than air conduction of sound.

A

The nurse is preparing to administer the Denver II Developmental Screening Test to a preschool-age child. Which areas of the child's development should the nurse explain to the mother that this test measures? Select all that apply. A. social B. language C. fine motor D. intelligence E. gross motor skills

A,B,C,E

The nurse is identifying ways to support the 2030 National Health Goals during the upcoming preschool health screening program. What should the nurse include when conducting the program? Select all that apply. A. Conduct vision tests. B. Conduct hearing tests. C. Listen to heart sounds. D. Measure gait and balance. E. Review immunizations received.

A,B,E

When beginning a physical examination of a toddler, the nurse notes that the child has halitosis. The nurse will perform a focused assessment on which body system(s) to assess for the source of the halitosis? Select all that apply. A. lungs fields during a respiratory assessment B. urine specimen during a urinary tract assessment C. any open areas during an integumentary assessment D. bowel sounds during a abdominal assessment E. oral cavity during a gastrointestinal assessment

A,E

A 6-year-old child is brought to the facility by the parents who report that the child has had a fever for the past 2 days and now is reporting ear pain and pressure. The nurse conducts an otoscopic exam and suspects an inner ear infection based on which assessment finding? A. dark-brown substance lining the ear canal B. bulging tympanic membrane C. clearly discernible malleus D. presence of cone of light

B

The nurse is interviewing the parents of a 3-year-old child brought to the emergency department for fever and fussiness. Which question is the best example to use when completing a health history about pain? A. "Your child doesn't have any pain, does she?" B. "Does your child have pain?" C. "So, your child has been fussy?" D. "Tell me about your child's temperament."

B

The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first? A. Palpation B. Inspection C. Percussion D. Auscultation

B

The nurse is preparing to care for a preschool-age child scheduled for a health history and physical assessment. At which point will the nurse determine a nursing diagnosis that is appropriate for the child's care? A. prior to the assessment B. at the time of assessment C. after completing the review of systems D. after specific problems have been identified

B

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? A. Snellen vision testing B. Blood pressure recording C. Observation of walking gait D. Standing height measurement

B

The nurse is preparing to conduct the cover test with a preschool-age child. Which body system is the nurse preparing to assess? A. Ears B. Eyes C. Nose D. Neck

B

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal? A. One to two per minute B. Five to 10 per minute C. Thirty to 40 per minute D. Sixty per minute

B

While caring for a child recovering from viral pneumonia, the nurse examines the child's lungs for evidence of exudate and fluid. Which finding would suggest cause for concern? A. a respiratory rate of 20 heard on auscultation B. dullness of his lower lobes heard on percussion C. a longer inspiratory than expiratory rate noticed by inspection D. fine rhonchi heard in the upper lobe on auscultation

B

The nurse is assessing eye alignment in a 6-year-old child. Which assessment method is most appropriate? A. asking the child to stare at a distant mark B. asking the child to touch the finger to the nose C. covering one eye and then removing the cover D. turning a bright light on and then off

C

The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this client? A. stridor B. crackles C. rhonchi D. wheezing

C

The nurse is observing a novice nurse measure the head circumference of a 9- month-old infant. The nurse determines that the novice nurse is performing the skill correctly based on which action? A. Measuring from the hairline in front to the hairline in back. B. Measuring from the center of the forehead to the posterior fontanel (fontanelle). C. Measuring from above the eyebrows through the prominent part of the occiput. D. Measuring from the middle of the forehead through the parietal prominences.

C

Which finding would the nurse interpret as least significant when assessing a child's lungs? A. stridor B. crackles C. rhonchi D. wheezing

C

The nurse is beginning a health history with a 3-year-old child. Which question would the nurse ask the mother first? A. "Is your child ill in any way?" B. "Tell me about your child." C. "Has your child been ill in the past?" D. "Do you have any concerns about your child?"

D

The nurse is planning an education session for adolescent males on health promotion activities. Which topic should the nurse include as being the most applicable for this population? A. reproductive cycle B. immunization schedule C. importance of socialization D. testicular self-examination

D

Which site would be best to use to take the temperature on a 12-month-old infant seen in an emergency room? A. Rectum B. Axilla C. Mouth D. Tympanic membrane

D