Health Assessment Ch.27 Children and Adolescents PrepU

The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse?

perianal lacerations extending to external sphincter

The nurse's inspection of a young child's anus reveals the presence of hemorrhoids. How should the nurse best interpret this assessment finding?

Hemorrhoids are unusual in children and warrant further assessment.

The nurse is preparing a teaching session for a group of adolescent high school students. What should the nurse include in this teaching? Select all that apply.

Methods to prevent pregnancy, Explanation of how pregnancy occurs, Transmission and prevention of sexually transmitted infections

A nurse measures an 18-month-old child's head circumference (HC) and finds that it is in the 3rd percentile. Which of the following conditions should the nurse suspect in this child?

Microcephaly

A child is repeatedly observed using the hand to push the nose upwards and backwards. What associated physical sign should the nurse assess for?

discoloration of the lower orbitopalpebral grooves

The nurse is collecting the history on a child and discovers that the child has missed a recommended vaccination. What is the nurse's best recommendation?

Encourage a catch up dose as soon as possible.

While performing an assessment on a 14 year old, the nurse notes the child has limited range of motion of the neck. The nurse recognizes this could be caused by what?

Meningitis

A mother of a 4-year-old asks the nurse when the child will begin to lose his baby teeth. What is the correct response by the nurse?

"Baby teeth will begin to be replaced by permanent teeth about age 6 years."

During the health assessment interview, which question should the nurse ask the parents of a preschooler to determine the child's level of motor development?

"Can your child run, hop, and skip?"

The nurse is assessing the hearing of a 10 year old. Which instruction should the nurse give the child who is undergoing conventional audiometry?

"Raise your hand when you hear a sound."

The nurse is discharging a 9-year-old child from the hospital and is transporting him via wheelchair to the parents' car. The father states, "Go ahead and put him in the front seat." What response from the nurse would be most appropriate?

"The child should sit in the back seat until 12 years old or of adult size. The air bags can cause harm if deployed."

The nurse is examining a 3-year-old girl who becomes distressed during the examination. What should you tell the parents?

"This behavior is developmentally appropriate."

Children at a day care center are going to the pool. The instructions to parents are for all children to bring sunscreen. An African-American parent states to the nurse, "It is not necessary for my child to wear sunscreen." What is the best response from the nurse to this parent?

"We would like all children to wear SPF 15 sunscreen for protection, no matter what skin type or color."

The nurse is conducting a prenatal history. Which question would be included in a prenatal history?

"Were there any difficulties with the pregnancy?"

What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status?

"What do you eat in a typical day?"

The nurse is preparing to assess the distance visual acuity of a 5-year-old child. How far from the Snellen chart should the nurse position the child?

10 feet

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child?

5 year old

The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child?

24 breaths/minute

The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age?

3

The nurse is conducting a vision-screening program for children age 3 to 10 years. The nurse would expect a child to have 20/20 vision at what age (in years)?

6 to 7

The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital?

An infant is placed in a forward facing car seat.

A nurse recognizes that a most valuable communication tool when working with small children is what technique?

Actively engage in play

A nurse should implement which important criterion to promote an effective nurse-parent communication when conducting a parent interview as a part of the child assessment?

Allow privacy for interview

A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam?

Allow the child to place the hand under the examiner's hand

A child tells the school nurse that she vomited and her "tummy hurts bad." She points to the lower right quadrant of the abdomen. These symptoms lead the nurse to be concerned with what condition?

Appendicitis

The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the following should the nurse suspect?

Appendicitis

The nurse is assessing a 4-year-old child with complaints of pain and vomiting. which of the following should the nurse suspect?

Appendicitis

A 6-year-old boy is brought to the emergency department by his parents, who state that he has been crying and saying his tummy hurts. Which method would be most appropriate initially to assess the problem?

Ask the child to point with one finger where it hurts.

The nurse is conducting an assessment of an adolescent. On which areas should the nurse focus a risk assessment and health-related teaching? Select all that apply.

Drug use Suicide Car safety

The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?

Ask the mother to leave the room.

A school nurse plans to test hearing acuity in students who range between kindergarten and sixth grade. What would be most appropriate method?

Audiometry

When assessing adolescent girls, the nurse should know that what usually appears first?

Breast buds

Children develop speech in a predictable manner. Which of the following statements is true regarding speech development in children?

By 18 months of age, a child has a vocabulary of approximately 50 words

A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?

Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

A 12 year old adolescent female presents to the clinic alone requesting birth control and testing and treatment suspected chlamydia. What is the nurse's priority action?

Check state regulations about testing and treatment of minors.

A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe?

Children typically have higher pitched heart sounds.

During the health history, a nurse asks a mother to describe the play activities of her school-age son. The mother reports activities that are typical for this age group. The nurse would document this as which type of play?

Competitive

Tommy, an 18-month-old, is seen in the clinic for otitis media. The nurse notes that Tommy coos and babbles but does not say distinct words. Which nursing diagnosis is most appropriate?

Delayed growth and development

The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate?

Denver Developmental Screening

The nurse has identified a need to discuss sexuality with a 15-year-old client. How should the nurse best plan this aspect of the health interview?

Discuss the matter when a parent is not present.

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?

Document the finding in the child's chart

A teacher refers a child to the school nurse, concerned that the child's speech is difficult to understand and not at the same level as other children in the age group. What information would be a priority for the nurse to obtain from the parent of this child?

Does the child have a history of frequent ear infections?

Upon assessment of the child's eyes, they deviate inward. The nurse recognizes this as what?

Esophoria

When examining visual acuity on a 30-month old child, the nurse should assess for what?

Fixation preference

The nurse is meeting the parents of an ill child for the first time and is preparing to perform the health interview. In addition to gathering health data, what additional goal should the nurse prioritize during this interaction?

Foster trust with the child's parents.

While attempting to auscultate heart sounds a 2-year old client pushes the nurse's hand away. What should be done to facilitate this assessment?

Give the child something to hold in each hand

The nurse obtains the following data about a 3-year-old child during an assessment at the neighborhood health clinic. Which finding would indicate a need for further evaluation of the child?

Has an undescended testes.

Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child?

Have the child blow a pinwheel.

The nurse inspects a 10-day-old infant's umbilicus and notes that it is reddened with the presence of slight discharge. What nursing diagnosis is suggested by these data?

Infection

The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?

It is likely a breast but which is a normal finding at this age.

During palpation of the abdomen, the nurse assesses the liver of a small child. Which of the following would the nurse expect to find?

It is located 2 cm below the right costal margin.

A child is crying when the nurse enters the examination room. What response should the nurse make in order to minimize the child's distress related to the physical examination?

Listen to heart and lung sounds first.

The nurse is beginning a physical assessment of a 3-year-old child, who becomes restless and begins to cling to the parent. Which assessment is a priority before the child becomes upset?

Listen to heart sounds.

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

The nurse prepares to assess an 18-month-old child. Which action should the nurse perform?

Obtain the apical heart rate before taking other vital signs.

The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child?

On the parent's lap

The nurse is speaking to a local PTO about childhood obesity. What would the nurse cite as the consequences of childhood obesity? (Select all that apply.)

Poor self-esteem, metabolic syndrome, hypertension

Which information would a nurse include when taking a health history on a child, but omit with an adult?

Prenatal history

A nurse prepares a play room for the children in a pediatric nursing unit. The nurse knows that which type of toys is best suited for toddlers?

Push-pull toys

How should the nurse document normal range of motion (ROM) in a child?

ROM full with 4-5+/5 strength symmetrically

A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention?

Raise head of bed and apply oxygen.

A nurse has completed an assessment of a school-age child. The nurse has identified several "soft signs" of potential neurologic impairment. How should the nurse best interpret these findings?

Recognize that the findings may or may not indicate the presence of a neurologic problem.

Which of the following is the most accurate method of determining the length of a child under 24 months of age?

Recumbent length measured in the supine position

Which test would the nurse perform to detect the presence of a congenital cataract?

Red Reflex

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage?

Relative sexual indifference and interaction with same-sex peers

The nurse would suspect appendicitis as the cause of pain if the child pointed to what location?

Right lower quadrant

The nurse is conducting a health education program on sexual health for adolescents. Which would be inappropriate for the nurse to include?

STI promotion

The use of alcohol and drugs in adolescence is often a means of what?

Self-medicating for other problems

A child 2 years of age or older should consume no more than 2,400 mg/day of what element?

Sodium

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 2

The nurse has assessed the head circumference (HC) of an 18-month-old during a regular checkup. The nurse should compare the percentile of the child's HC to which of the following?

The child's height and weight percentiles

The nurse is performing an assessment on a child. How should the blood pressure cuff fit on the child's arm?

The cuff should cover 80% of the child's upper arm.

During palpation of a young child's abdomen, the nurse assesses the liver. What would the nurse expect to find?

The liver is located 2 cm below the right costal margin.

A 14-year-old girl comes to the clinic and requests to be seen for suspicion of a sexually transmitted disease (STD). What is the nurse's responsibility for treatment of this adolescent?

The nurse understands that it is not necessary to have parental consent to treat an STD in a child 13 years or older.

The nurse is conducting a health history with an adolescent patient. What should the nurse explain to the patient about confidentiality?

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

The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding?

This is a normal finding for a toddler.

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

Three

What should the nurse consider when discussing language development with parents of toddlers?

Toddlers express themselves with combination words.

The nurse is evaluating the results of a 11-month-old who underwent visual reinforcement audiometry. When interpreting the results, the nurse recognizes that:

Unilateral hearing loss cannot be ruled out.

The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?

Unstable gait

The nurse determines the heart rate of 100 beats per minute for a 5-year-old patient as being:

Within normal limits

The nurse is preparing to assess the heart sounds in a 3-year-old child. To locate the apical impulse, the nurse should plan to place the stethoscope at the child's

fourth intercostal space.

While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of

iron

A woman who speaks primarily Spanish at home brings her 3-year-old to the clinic for a yearly visit. The mother reports concern that her child's language skills are not progressing as expected. The health care provider may have a difficult time assessing this child's language capabilities if

the provider is not bilingual