Chapter 27: Children & Adolescents

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?" Rationale: The most appropriate question for the parents of a preschooler would be to ask if the child can run, hop, and skip. Running, hopping, and skipping indicate the level of motor development in the child. The nurse need not ask the parents if the child can scribble, because at 15 months the child can spontaneously scribble. Parents of a toddler should be asked if their child can walk up and down the steps and jump with both feet.

The nurse is conducting an assessment of Maggie, an 12-year-old child. Which statement by the mother would concern the nurse most?

"Maggie's dresses and shirts don't hang right." Rationale: Maggie's clothes may not fit well due to an unevenness in shoulder height, which may be a sign of scoliosis. Breast development in girls occurs after age 8 years. While it is important for the nurse to know Maggie wears contacts and had her tonsils removed, they are not of concern to require follow-up.

A nurse is assessing the moral development of an 11-year-old-child. The nurse determines normal moral development has been achieved when the parents make which of the following statements?

"Our child is always trying to please us." Rationale: Between the ages of 10 and 13 years of age, children are at the conventional level of Kohlberg's moral development theory. The school-age child wants to please and conform to social norms. If a school-age child is not conforming and is always getting into trouble, they have not met the conventional level. Knowing what is morally right and wrong occurs at the postconventional level of morality during adolescence (13 and older). Distraction to prevent injury is used with toddlers who are in the substage of the preconventional stage, which involves punishment and reward.

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 Rationale: For children ages 2 to 10 years of age, the normal respiratory rate ranges from 20 to 28 breaths per 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 Rationale: A 4-year-old child is generally talkative and engaged in the visit and can answer simple questions about self and concerns . Listen for speech difficulties. By 2 years of age, the child uses two-word sentences; by 3 years of age, a child should speak in more complicated sentences with speech that is understandable 75% or more of the time.

Senior-year nursing students are spending a clinical day with the school nurse of an elementary school. Today, vision and hearing screenings are being conducted, and the students are expected to help with the screenings. With what age group would the students be expected to screen for color blindness?

4 to 8 years Rationale: Screening for color blindness is usually conducted in clients 4 to 8 years old. Therefore, the other options are incorrect.

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

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

A nurse is assessing a 2-year-old for achievement of normal developmental milestones. Which of the following skills demonstrates normal cognitive development for a 2-year-old?

uses two- to three-word phrases Rationale: At the age of 2, toddlers possess a 300-word vocabulary and can state two- to three-word phrases. At the age of 4, a preschooler has a 1,500-word vocabulary. Five-year-old preschoolers are able to state four or more colors. Younger toddlers at the age 15 months use expressive jargon (pointing at objects and making sounds and tones).

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. Rationale: The infant seat should be in the back seat, facing backward, for at least the first year of the child's life. Depending on the construction of the car seat, it may be in the back seat facing backward until the child weighs 30 to 35 lb. A child may face forward after 1 year of age in some types of car seats. At 4 years of age (or at 40 lb), the child may switch from a car seat to a booster seat. The child should be seated and restrained with the automobile's seat belt in such a booster seat, which is designed for use until he or she is at least 49-in. tall. Children who have outgrown the booster seat should ride in the back with a seat belt fastened securely. A child may move to the front seat after 12 years of age if he or she is of adult size. Front air bags have been known to hurt younger and smaller children because of the force with which they are deployed.

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

Breast buds Rationale: Breast development occurs first. This is followed by the growth of pubic hair, axillary hair, and then menarche.

While assessing the head and neck of an 11 year old child, the nurse palpates several tender and swollen lymph nodes. What is the nurse's best action?

Prepare to collect blood to analyze white blood cell count. Rationale: Tender swollen lymph nodes of the neck and back of the head may indicate an infection. Lymph nodes are frequently palpable in children but they should be small, cylindrical, movable, and nontender. Limited neck ROM requires further evaluation for possible meningitis or torticollis. The lymphatic system grows exponentially between 6 and 12 years and reaches adult size around 12 years. Therefore, tonsils frequently look large at this time but will appear smaller as the head and neck grow throughout adolescence

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 Rationale: The nurse should keep push-pull toys for the toddlers in the play room because toddlers play alongside and engage in locomotive play. Play tents and doctor kits are ideal for preschoolers because they engage in interactive and associative play. Board games are ideal for school-age children because they engage in competitive play.

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

ROM full with 4-5+/5 strength symmetrically Rationale: In children, nurses observe for ROM and musculoskeletal symmetry and coordination. Normal ROM for them is full with 4-5+/5 strength symmetrically. ROM full is not acceptable because it is not a complete documentation. A ROM of 3/5, regardless of whether the strength is symmetrical, is not an expected finding for a child. The initials WNL mean a range, not a specific finding.

What is an appropriate action by a nurse when asking a child about the presence of pain?

Use a pain scale appropriate for the child's developmental level Rationale: Pain is a subjective finding and both the parent and child should be asked about the presence of pain, especially in smaller children because they may have trouble verbalizing how they feel or where it hurts. The use of pain scale appropriate to the age of the child will help the nurse to obtain data about how severe the pain is. The FACES or the Oucher scales are appropriate to use with small children. The numeric scale may be used with older children and adolescents.

The nurse is performing a cardiopulmonary assessment on a 6-year-old client. Which finding would cause the nurse to anticipate treatment for pertussis?

a violent cough with a "whoop" sound at the end Rationale: Pertussis is respiratory disorder characterized by a paroxysmal cough with a "whoop" at the end. Meningitis is associated with nuchal rigidity. A hollow, machinery-like murmur is heard in clients with patent ductus arteriosus. Bluish discoloration of the lips is associated with generalized cyanosis.

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

Appendicitis Rationale: Abdominal pain and vomiting are classic clinical manifestations of appendicitis. Otitis media causes an ear ache but not vomiting. Hypospadias is an abnormal opening of the urethra on the underside of the penis. Cryptorchidism is a term to describe undescended testicles. Hypospadias and cryptorchidism do not cause pain and vomiting.

A school nurse plans to test hearing acuity in kindergarten through sixth grades. Which of the following would be most appropriate method?

Audiometry Rationale: Audiometry would be most appropriate for testing hearing acuity in school-age children because it measures the threshold of hearing for frequencies and loudness. At this age, hearing acuity is almost complete. Initially, hearing acuity can be evaluated by the whisper test. The Weber test would be used if a hearing deficit is noted to distinguish between a conductive and sensorineural hearing loss.

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. Rationale: Most states permit contraception and treatment for sexually transmitted infections at 13 years of age; therefore the nurse should first check state regulations regarding a 12 year old seeking treatment before collecting urine sample or cervical exam is performed.

During assessment of a 2 year old child, which assessment by the nurse would best indicate possible hydrocephalus?

Head circumference Rationale: Measuring head circumference, especially during the first 3 years, may identify neurological abnormalities as well as malnutrition. Identification of abnormal growth patterns can lead to early diagnosis of treatable conditions, such as hydrocephalus or identification of disorders associated with slowed head growth, such as Rett syndrome.

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. Rationale: Hemorrhoids are unusual in children and could be due to chronic constipation but may be caused by sexual abuse or abdominal pressure from a lesion. Further assessment is thus warranted. This finding is not suggestive of a fluid deficit or cancer.

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 Rationale: Recumbent length is used to measure the height of children less than 2 years of age. Children under the age of 2 years may not able to stand erect. All heights/lengths should be measured and documented accurately.

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

Red reflex Rationale: The nurse would observe the red reflex; the reflex will be absent in the presence of a congenital cataract. Distance visual acuity is assessed using the Snellen chart and the Tumbling E. Ocular alignment is assessed using the random dot E stereo test at 40 cm.

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 Rationale: School-age children who are in the latency period of the psychosexual development stages have sexual indifference and tend to interact with same-sex peers. In a preschooler, pleasure is centered on masturbation and genitalia. Adolescents engage in masturbation and sexual activities with others. In toddlers, the erogenous zones are the anus and buttocks, and their activities are centered on expulsion and retention of body waste.

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

STI promotion Rationale: The nurse would include information on preventing sexually transmitted infections and pregnancy and self exam of the breasts and testes.

After completing a developmental assessment, the nurse determines that a 3-year-old client is following normal developmental patterns. What did the nurse assess in this client?

Talks using complete sentences Rationale: One developmental milestone is language and speech development. For the 3-year-old client, a developmental milestone is the ability to speak using complete sentences. Talking with two to three words would be appropriate for a 1-year-old client. Talking with two- to three-word phrases would be appropriate for a 2-year-old client. Defining words would be appropriate for a 5-year-old client.

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. Rationale: Legal consent for health care treatment is 18 years of age. Most states, however, permit contraception and treatment for STDs at 13 years of age.

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

5 year old Rationale: The Denver Developmental Screening Test II (DDST-II) (Frankenburg, Dodds, Archer, Shapiro, & Bresnick, 1992) is one of several standardized developmental screening tests used in the examination of the child and required for early and periodic screening and developmental testing. The DDST-II is considered the standard criterion for the developmental evaluation of children aged 1 month to 6 years. It evaluates four developmental areas of interest: personal/social, language, fine motor/adaptive, and gross motor.

A parent voices concern about the amount of time their school-age child sleeps. When responding to the parent, the nurse understands that this child's age group sleeps an average of how many hours each night?

8 to 9.5 Rationale: School-age children's sleep patterns vary but typically range from 8 to 9.5 hours each night, not 11 to 13, 9.5 to 11, or 7 to 8 hours. Toddlers average about 12 hours of sleep each night. Preschoolers average about 11 to 13 hours of sleep each night.

A nurse is conducting an interview with the parents of an adolescent (14 years old). Which responses by the parent would require further follow-up by the nurse regarding their child's sensory perception? Select all that apply.

> "Our child sits right on top of the television." > "Our child complains frequently of a headache." > "We are constantly telling our child to turn down the music." Rationale: There might be a problem with hearing or vision if a child sits close to the television set or plays music loudly. Even though it is normal for adolescents to play loud music, the nurse should further investigate hearing as well as vision problems. Frequent headaches are another sign of possible visual deficiencies. The other two responses (about diet and school) are normal. If the parents reported that their child was reversing numbers and letters, the nurse should assess for dyslexia.

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 Rationale: Risk assessment and health-related teaching foci for adolescents include car safety, drug use, and suicide. Poison control and fire safety are key areas of risk assessment and health-related teaching for younger aged children and their families.

What strategies can the nurse use when examining the ears of a 4-year-old client? Select all that apply.

> Pull the auricle up and back. > Insert the speculum .25 to .5 inches (.64 to 1.27 cm) into the canal. > Apply minimal pressure. > Use a hand to provide a buffer against sudden movements. Rationale: Strategies to help with the ear examination of a 4-year-old client include pulling the auricle up and back, inserting the speculum .25 to .5 inches (.64 to 1.27 cm) into the canal, applying minimal pressure, and using the lateral aspect of the hand that is holding the otoscope against the client's head to provide a buffer against sudden movements by the client. The auricle should be pulled down and back for clients under the age of 3.

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.

> Short, broad extremities > Hyperextensible joints > Palmar simian crease Rationale: Short, broad extremities, hyperextensible joints, and palmar simian crease may indicate Down's syndrome. A common finding in children (up to 2 or 3 years old) is metatarsus adductus deformity. This is an inward positioning of the forefoot with the heel in normal straight position, which resolves spontaneously. Tibial torsion, also common in infants and toddlers, consists of twisting of the tibia inward or outward on its long axis, is usually caused by intrauterine positioning, and typically corrects itself by the time the child is 2 years old. Talipes varus, a congenital deformity, is adduction of the forefoot and inversion of the entire foot.

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 Rationale: To decrease ticklishness, have the child help by placing the hand under the nurse's hand, using age-appropriate distraction and conversation focused on something other than the exam.

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 Rationale: Tommy is not exhibiting expected language/speech development for an 18-month-old and requires further evaluation immediately. Nursing diagnoses with "readiness" indicate the family is operating at a level that supports the well-being of family members and desires to promote the health of the family and function at a higher level. Whether Tommy is experiencing disturbed sensory perception related to altered hearing, which may contribute to his delay in language/speech development, is not clear.

A nurse reviews the vital signs of a 1-year-old client: Temperature: 98.6° F (37° C), pulse 135 beats per minute, respiratory rate 30 breaths per minute. What is the best action of the nurse?

Document findings. Rationale: Because the vital signs are within normal range, the nurse would document the findings. Normal vital signs for a 1-year-old include temperature 98.6° F (37° C), pulse for 3-month-old to 2-year-old is 80 to 150 beats per minute, respiratory rate from ages 1 to 2 years is 22 to 37 breaths per minute. Because these are normal signs the nurse does not need to report the findings, reassess the pulse, or ask another nurse to reassess the respiratory rate.

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 Rationale: The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute. The nurse should record this normal 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? Rationale: A delay in speech development may signal hearing loss or mental health concerns. Traumatic events, vision problems, and siblings with speech difficulties are not indicators or causes of speech delays.

A mother of a preschooler asks the nurse what type of toys will promote the child's development. What should the nurse recommend to this parent?

Dress-up clothes Rationale: Preschoolers are at an age at which they enjoy imaginary playmates. They also like to imitate others, especially their parents. Dress-up clothes, housekeeping toys, doctor and nurses kits, play tents, and puppets are good toys for a child this age. Board games and complex puzzles are good for school-age children to help them learn rules and complex thought. Preschoolers have mastered movement but need toys that will promote growth and development. Push-pull toys are appropriate for toddlers.

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

Esophoria Rationale: Esophoria is eye deviation inward. Exophoria is eye deviation outward. Nearsightedness is the ability to see up close. Farsighted people are unable to see distances.

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. Rationale: Establishing trust and rapport with the child's parents is imperative during early interactions. Each of the other listed goals may be appropriate and applicable to many families, but therapeutic care is not possible in the absence of trust between the nurse and the family.

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

Have the child blow a pinwheel. Rationale: The nurse can assure adequate deep breaths for assessment of lung sounds by having the child blow a pinwheel. Having the child say 99, 99, 99 assesses the density of the lung tissue not breath sounds. Hopping on one foot and skipping around the room gives the nurse information regarding the child's sense of balance and motor development.

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 bud which is a normal finding at this age. Rationale: Breast development begins with a "breast bud" or enlargement of the areola followed by enlargement of breast tissue. The onset of pubertal changes before 8 years in girls and 9 years in boys may be too early and needs further evaluation.

During palpation of the abdomen, the nurse assesses the liver of a 4-year-old client. Which of the following would the nurse expect to find?

It is located 2 cm below the right costal margin. Rationale: The liver is usually palpable 1 to 2 cm below the right costal margin in young children; therefore, the nurse should not expect the liver to be unpalpable. An enlarged liver with a firm edge that is palpated more than 2 cm below the right costal margin usually indicates a pathologic process.

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 Rationale: Redness, edema, and tenderness in the breasts indicate mastitis. Enlargement of the breasts in adolescent boys suggests gynecomastia. Masses in the adolescent female breast usually indicate cysts or trauma. Breast development before age 8 may indicate precocious puberty or thelarche.

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 Rationale: HC not within the normal percentiles may indicate pathology. A finding greater than 95% may indicate macrocephaly. A finding under the 5th percentile may indicate microcephaly. Increased HC in children older than 3 years may indicate separation of cranial sutures due to increased intracranial pressure.

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. Rationale: The heart rate should be obtained first followed by breath sounds, especially if it is expected that the child may become upset during the exam. The respiratory rate should be counted for an entire minute to ensure accurate measurement. Most children less than age 3 years are more comfortable sitting in their parent's lap during the exam.

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

On the parent's lap Rationale: A toddler can remain in the parent's lap to decrease anxiety. An examination table may increase anxiety, a stool is not safe and a toddler will not remain inactive long enough to stand

What developmental area does the DDST-II evaluate?

Personal social Rationale: The DDST-II is considered a gold standard for the developmental evaluation of children aged 1 month to 6 years. It evaluates four developmental areas of interest: personal social, language, fine motor/adaptive, and gross motor. The DDST-II does not evaluate education, cooperation, or cognition.

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

Prenatal history Rationale: Certain childhood problems and conditions can be associated with the prenatal, intrapartal, and/or neonatal periods. This information is not necessary for an adult.

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 Rationale: Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually occurs from a respiratory disorder or significant blood loss. Children rarely present in acute distress from ischemic heart disease and resulting dysrhythmias. The child in respiratory distress presents with nasal flaring and chest retractions or abdominal breathing. Administration of oxygen and support of the child's ability to breathe are the first interventions. Then a medical history and list of medications can be obtained.

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. Rationale: Soft signs of neurologic problems are controversial, because these signs do not always indicate a pathologic process. Referral may be necessary, but not likely on an emergency basis. These signs are unlikely to be closely related to educational level or developmental tasks.

Which assessment finding supports a diagnosis of scoliosis?

The right hemi-thorax is generally prominent. Rationale: The right hemi-thorax is generally prominent in cases of scoliosis. None of the other options suggest information that is associated with scoliosis.

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. Rationale: A protuberant abdomen is a common finding for a toddler.

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

Toddlers express themselves with combination words. Rationale: Toddlers are age 1 to 3 years. Language development occurs rapidly during this developmental period. Sentences become more complicated, and by the age of 3 years, pre-schoolers are completely understood by most people.