Chapter 34 Child Health Assessment PrepU

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?" "Has your child exhibited any symptoms?" "Has your child exhibited a fever and vomiting?" "Your child hasn't exhibited a fever, has she?"

"What symptoms has your child exhibited?"

The nurse is performing a health history on a 6-year-old child who is having trouble adjusting to a new school. Which question will elicit valuable information? "Do you like your new school?" "Are you happy with your teacher?" "Do you enjoy reading a book?" "What are your new classmates like?"

"What are your new classmates like?"

An anal fissure is observed as the nurse completes a health assessment on an 8-year-old child. What question is most important for the nurse to ask the child? "Have you have any rectal itching at night?" "How often do you have a bowel movement?" "Do you have any bleeding when having a bowel movement?" "Can you describe the pain you are having?

"How often do you have a bowel movement?"

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? "I wish there was a blood test for alcohol use disorder. I know my son is at risk." "Our next door neighbor is older than my son, and he drinks when they hang out together." "I think I know how my son feels about drinking. He has had substance use disorder education in school." "Sometimes my son asks me questions about his father's low tolerance for alcohol."

"Our next door neighbor is older than my son, and he drinks when they hang out together."

The caregiver of a 3-year-old boy presents at the receptionist desk and reports that the child is nauseated. In interviewing the child's caregiver, which question should the nurse prioritize when starting the assessment? "Why did you decide to bring your son to the clinic today?" "How often does your son complain of being nauseated?" "Does anyone else in the family have the same symptoms?" "Has your son had anything to eat that he might be allergic to?"

"Why did you decide to bring your son to the clinic today?"

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: 12-hour recall. 24-hour recall. 3-day recall. 1-week recall.

24-hour recall.

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? 99.3°F (37.4°C) 96.6°F (35.8°C) 100.3°F (38.4°C) 99.8°F (37.9°C)

96.6°F (35.8°C)

The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation? A bubble behind the tympanic membrane A pearly pink membrane A mobile tympanic membrane A gray tympanic membrane Visible bony landmarks behind the membrane

A bubble behind the tympanic membrane

The nurse is assessing a 4-year-old child brought to the emergency department due to abdominal pain. Which method(s) will the nurse use to complete a focused symptom assessment? Select all that apply. Ask the child to point to the location of symptoms. Ask the parent what seems to aggravate or relieve their child's pain. Ask questions to see if the child is lying about symptoms. Note if there are any associated factors or symptoms. Identify if there is a setting in which symptoms occur.

Ask the child to point to the location of symptoms. Ask the parent what seems to aggravate or relieve their child's pain. Note if there are any associated factors or symptoms. Identify if there is a setting in which symptoms occur.

A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam? Explain the procedure to the child. Allow the child to play with the tuning fork. Demonstrate the procedure on the mother. Explain that no pain is involved.

Allow the child to play with the tuning fork.

The nurse is assigned to work in the triage area of a pediatric clinic when a 4-year-old child and parent arrives. Which communication technique will the nurse use when determining the chief concern? Ask the child or family member, "Why have you come to the clinic today?" Ask the child, "Is it ok if I begin my physical assessment to see what is the matter?" Ask the parent, "What do you see as the reason your child is sick?" Ask the child, "Can you tell me if you have ever felt like this before?"

Ask the child or family member, "Why have you come to the clinic today?"

While assessing a 6-month-old, the nurse notes the posterior fontanel (fontanelle) is open. What action should the nurse take next? Notify the health care provider. Assess the anterior fontanel (fontanelle). Document the finding in the chart. Review the baby's history.

Assess the anterior fontanel (fontanelle).

The nurse is caring for a child and notes mild cyanosis of the fingertips. Which action will the nurse complete next? Assess the child's oxygen saturation level. Notify the primary health care provider. Determine the child's heart rate. Document the finding in the medical record.

Assess the child's oxygen saturation level.

A nurse is performing a physical examination on a newborn. Which assessment should the nurse include? Axillary temperature, femoral pulse, head circumference Rectal temperature, femoral pulse, head circumference Temporal temperature, blood pressure, reflexes Oral temperature, blood pressure, head circumference

Axillary temperature, femoral pulse, head circumference

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 Above the sternum, slightly to the right Below the ribs about one half of an inch Above the clavicle on the left side

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 fontanel (fontanelle) and open posterior fontanel (fontanelle) Open anterior fontanel (fontanelle) and closed posterior fontanel (fontanelle) Closed anterior and posterior fontanels (fontanelles) Open anterior and posterior fontanels (fontanelles)

Closed anterior and posterior fontanels (fontanelles)

The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam? Convey the impression that there are no right or wrong answers. Have the child read each of the 22 words from a sheet of paper. Modify the directions of the test using the nurse's own discretion. At the end, explain which words the child missed and why.

Convey the impression that there are no right or wrong answers.

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. Applaud the good technique. Explain why the technique is incorrect. Counsel the new graduate.

Demonstrate the appropriate technique.

An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first? Determine the type of ingestion. Call poison control. Initiate a nasogastric tube. Administer activated charcoal.

Determine the type of ingestion.

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? Obtaining the health history Interviewing the client Obtaining biographical data Determining the chief complaint

Determining the chief complaint

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. Examine the child's chest and then go to the head and down. Examine the child's extremities first and then the chest. Examine different sections of the body at various times.

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

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? Do you have the immunization book for us to review? When did the child have his/her last immunization? Were there any side effects from the last immunizations?

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

The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason? The number of family members that have a certain health problem will help the nurse know if the child will have the same problem. Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. The nurse needs to know everything about a family to take care of the child. By establishing family behavior, the nurse forces the parents to alter their care of their child and make them healthier.

Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems.

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? Coping strategies of the child Past accidents the child was involved in Immunization record Recent or past hospitalizations

Immunization record

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? Closed-ended Open-ended Compound Expansive Leading

Open-ended

The parents bring the child for a health exam. After eliciting a chief concern from the parents, the nurse continues gathering information about related and other health concerns. Why is it important for the nurse to ask a second time at the end of the interview if there are other concerns? Parents always have more than one concern. Parents will not always reveal their most important concern in the initial minutes of the interview. The nurse should help assuage any parental fears before ending the interview. Parents might have concerns that are not so important and should accurately be addressed at the end of the interview.

Parents will not always reveal their most important concern in the initial minutes of the interview.

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? Infancy Preschool age School age Adolescence Young adulthood

School age

To obtain an accurate heart rate in an infant, what would be most important for the nurse to do? Take the apical pulse. Count the pulse rate for 30 seconds. Use an electronic stethoscope. Take a radial pulse.

Take the apical pulse.

When obtaining a child's health history, the child's demographic data is assessed first. What should the nurse assess next? Types of medications the child takes How the child feels school is going The chief complaint of the child History of illness

The chief complaint of the child

What is typical of a grade II heart murmur? The murmur is soft but easily heard. The murmur is soft and hard to hear. The murmur is loud with an associated thrill. The murmur is loud without an associated thrill.

The murmur is soft but easily heard.

The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child? The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The nurse should weigh the parent on a standing scale and then weigh the parent again while holding the child. The nurse should ask the parent to lightly hold the child's hands while the child is sitting on the scale. The nurse should lay the parent on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight.

The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.

When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested? The reflex is brisk. The reflex is hyperactive. The reflex is diminished. The reflex is absent.

The reflex is diminished.

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 Syringe IV bag

Thermometer Stethoscope Tongue depressor Ophthalmoscope

A nurse is assessing the fontanels (fontanelles) of a crying newborn and notes that the posterior fontanel (fontanelle) pulsates and briefly bulges. What do these findings indicate? Increased intracranial pressure Overhydration Dehydration These are normal findings.

These are normal findings.

The nurse is taking the health history for a toddler in the emergency department. The child's parent informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection (UTI) 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint? Asthma Pneumonia Vomiting UTI

Vomiting

The nurse preceptor observes a novice nurse perform a pediatric assessment. Which action by the novice nurse will the nurse preceptor determine is a normal variance to assessment technique when compared to the assessment of an adult patient? skipping the review of systems portion of the assessment assessing the abdomen before assessing the head and neck deferring the focused exam portion of the assessment assessing the mental status before assessing the lungs

assessing the abdomen before assessing the head and neck

The nurse is interviewing the mother of a child who is at the local clinic. When asked why she brought her toddler in today, she replies that the child has been running a fever and coughing a lot since last weekend. This information would be noted in the chart as what data? heath history present health concern chief complaint biographical history

chief complaint

The nurse is measuring an infant's head circumference and charts it to be at the 40th percentile. When documenting the following physical measurements, which correlation to the head circumference is anticipated? child's weight will be at the 80th percentile child's length will be at the 40th percentile child's chest circumference will be at the 20th percentile child's abdominal circumference will be at the 50th percentile

child's length will be at the 40th percentile

The nurse is caring for a child who has just arrived to the emergency department. The child is pale and has labored breathing. The nurse is inspecting the child while placing the child on oxygen, obtaining a pulse oximeter reading, and raising the head of the bed. Which assessment finding best reflects that the child's respiratory status is due to a chronic condition? pulse oximetry of 85% substernal retractions clubbing of the fingertips cyanosis

clubbing of the fingertips

The pediatric nurse is performing a head-to-toe exam on a 2-year-old child during a well child assessment. Which method will the nurse use to accurately determine the child's heart rate? palpating the brachial pulse counting the apical rate palpating the femoral pulse calculating the apical rate

counting the apical rate

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. refer for further evaluation. educate the parent about the abnormal finding. teach parent to have child wear hard-soled shoes.

document as a normal finding.

A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding? dorsiflexion of the newborn's toes curling downward of the toes fanning of the infant's toes withdrawing the foot from touch

fanning of the infant's toes

The nurse is performing a respiratory assessment on a black adolescent experiencing a sickle-cell crisis. Where is the best place for the nurse to check for cyanosis on this client? lips mucous membranes cheeks nail beds

mucous membranes

A nurse is assessing a 14-year-old client who has just been admitted to an acute care facility and notices that the patient has halitosis. Which are the usual causes of this problem for this age group? Select all that apply. poor dental hygiene lung infection acidosis foreign body in respiratory tract protein metabolic condition

poor dental hygiene, lung infection, foreign body in respiratory tract

Where is the point of maximal impulse (PMI) found in a 5-year-old child? the sternum the clavicle the third intercostal space the fourth intercostal space

the fourth intercostal space