Chapter 32- Health Assessment
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.
A A cremasteric reflex is elicited by stroking the medial aspect of the thigh in boys. With this, the testes move perceptibly upward. The presence of this reflex indicates integrity of the first and second lumbar nerves. Addn Info: Abdominal reflexes should be assessed in both sexes. An abdominal reflex is elicited by lightly stroking each quadrant of the abdomen. Normally, the umbilicus moves perceptibly toward the stroke. Presence of this reflex indicates integrity of the 10th thoracic nerve and the first lumbar nerve of the spinal cord. The new graduate nurse needs to be shown the correct aspect of the thigh to stroke so that she/he can perform the technique correctly in the future. Explaining why the technique is incorrect does not show the nurse how to perform the procedure correctly. The charge nurse would not want to applaud an incorrect procedure, nor is this reason to counsel the nurse.
The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education? "You should auscultate all four quadrants for a full minute each." "Hypoactive bowel sounds are expected in a client with diarrhea." "Bowel sounds should be present within the first few days of life." "Bowel sounds will be audible by the naked ear unless distention is present."
A During assessment, the nurse should auscultate each quadrant for a full minute when assessing bowel sounds.
While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nurse most likely be performing? assessing vision checking temperature asking the client if he or she likes school asking the client about what he or she usually eats each day
A Hearing and vision screenings are examples of secondary prevention in health assessments. These are usually state-or federally-mandated screenings to prevent risk factors of specific diseases.
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.
A Taking the apical pulse with a stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be taken with older children, as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lay close to the skin surface and are easily obliterated.
A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction? up down and back up and back forward
B The nurse should pull the pinna of the ear down and back for a child younger than age 3 years to help straighten the ear canal. For a child older than age 3 years, the pinna is pulled up and back.
The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing? Moro Babinski palmar grasp root
A The Moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs.
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.
A The infant should be assessed for a Babinski reflex. To achieve this stroke the sole of the foot. Fanning of the toes will occur in infants younger than 3 months of age. A downward reflex of the toes will occur beyond 3 months of age. Some infants will demonstrate a flaring Babinski sign until 2 years of age. In the absence of other neurologic findings this is a normal response. The nurse would document this normal finding.
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? swollen labia minora lesions on the external genitalia labial adhesions swollen and red anal area
A The newborn's labia minora is typically swollen from the effects of maternal estrogen. The minora will decrease in size and be hidden by the labia majora within the first weeks. Lesions on the external genitalia are indicative of sexually transmitted infection. Labial adhesions are not a normal finding for a healthy newborn. A swollen and red anal area would be an abnormal finding.
The nurse is assessing the vital signs of several toddlers in the pediatric medical unit. Which findings are of most concern to the nurse? Heart rate 60 beats per minute; respiratory rate 14 breaths per minute Heart rate 120 beats per minute; respiratory rate 28 breaths per minute Heart rate 100 beats per minute; respiratory rate 18 breaths per minute Heart rate 112 beats per minute; respiratory rate 24 breaths per minute
A The normal heart rate for a toddler ranges between 90 and 140 beats per minute and the respiratory rate ranges between 20 to 37 respirations per minute. A heart rate 60 beats per minute and respiratory rate 14 breaths per minute are both below the normal range for toddler.
The nurse is auscultating the lungs of a lethargic, irritable 6-year-old boy and hears wheezing. The nurse will most likely include which teaching point if the child is suspected of having asthma? "I'm going to have this hospital worker take a picture of your lungs." "We're going to go take a look at your lungs to see if there are any sores on them." "I'm going to have the respiratory therapist get some of the mucus from your lungs." "I'm going to hold your hand while the phlebotomist gets blood from your arm."
A The nurse should teach the child using terms a 6-year-old will understand. A chest x-ray is usually ordered for the assessment of asthma to check for hyperventilation. A sputum culture is indicated for pneumonia, cystic fibrosis, and tuberculosis; fluoroscopy is used to identify masses or abscesses as with pneumonia; and the sweat chloride test is indicated for cystic fibrosis.
All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? just above the eyebrows through the prominent part of the occiput the center of the forehead to the base of the occiput the hairline in front to the hairline in back the middle of the forehead through the parietal prominences
A To measure the circumference of an infant's head, the nurse would measure the largest point across the skull, not including the ears, with a no stretching cloth or paper tape. The tape would be placed at the forehead just above the eyebrows and brought around the head in a taut circle just above the occiput prominence at the back of the head.
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.
A When assessing heart murmurs, a grading scale is used to describe the sound of the murmur. A grade I murmur can barely be heard. A grade II heart murmur is usually soft and it is easily auscultated. A grade III murmur is audible. A grade IV murmur can be heard and has an associated thrill. The grade V murmur is loud and can be heard with the edge of the stethoscope lifted off the chest. The grade VI murmur is very loud and can be heard with the stethoscope near but not touching the chest.
The nurse is obtaining a functional history during an admission assessment of a 12-year-old child. Which questions would be appropriate for the nurse to ask during this part of the assessment? Select all that apply. "Can you tell me if you play any sports or participate in any physical activities?" "Do you know if your family has a history of any heart problems?" "Do you wear a seat belt any time you are a passenger in a car?" "Do you use a computer or a smartphone?" "Are your parents married?"
A,C,D The functional history should contain information about the child's daily routine. Questions such as the amount of physical activity, car safety, and use of computers and smartphones (including the amount of time on these devices) are included in this assessment.
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal? One to two per minute Five to 10 per minute Thirty to 40 per minute Sixty per minute
B The usual frequency of bowel sounds is 5 to 10 per minute.
The nurse is assessing the head, eyes, ears and neck of an 8-year-old child. Which assessment finding(s) by the nurse would warrant further investigation? Select all that apply. presence of cervical lymph nodes webbing of the neck inability to flex chin to chest ears located at eye level eyes midline when the child is looking forward
B, C Webbing or excessive neck skin folds may be associated with Turner syndrome, and lax neck skin may occur with Down syndrome. Older children will be able to look in all directions on command and stretch their chins to their chests themselves. Assessment of neck mobility is particularly important when infections of the central nervous system are suspected. Pain or resistance to range of motion may indicate meningeal irritation. Therefore, these two findings warrant further investigation. The eyes should look symmetric and both should be facing forward in the midline when the child is looking directly ahead. Ears should be symmetric and placed no lower than the eyes.
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)
C By age 18 months, the anterior and posterior fontanels (fontanelles) should be closed. The diamond-shaped anterior fontanel (fontanelle) normally closes between ages 9 and 18 months. The triangular posterior fontanel (fontanelle) normally closes between ages 2 and 3 months.
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
C Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.
Where is the point of maximal impulse (PMI) found in a 5-year-old child? the third intercostal space the sternum the fourth intercostal space the clavicle
C The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. Up until the age 4 years it is located between the 3rd and 4th intercostal space (ICS). From ages 4 to 6 years it is found at the 4th ICS medial to the left midclavicular line. From age 7 upward it is located at the 5th ICS lateral to the left midclavicular line. Heart sounds radiate and can be heard either to the right or left of the sternum but never directly over the sternum.
The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct? Once the child has grown these lesions are usually removed by lasers. Biopsies of these areas are usually taken once the child is a teen. These lesions will normally fade as the child ages. These lesions are associated with the development of Sturge-Weber syndrome.
C The lesions described are consistent with infantile (strawberry) hemangioma. They are benign and normally fade as the child ages, usually by the age of 9 years.
When assessing heart sounds on a high school athlete, the nurse hears a "lub d-dub" sound which is associated with inspiration. What action will the nurse take? Notify the health care provider. Refer the student for an electrocardiogram. Document the findings as normal. Refer the student for a stress test.
C With inspiration and the resulting increase or pressure in the lungs, the pulmonary valves close slightly later than the aortic valve. This causes a variation in heart sounds. This is termed physiologic splitting and is heard as a "lub d-dub" sound. As long as this sound is associated with inspiration, it is a normal finding. If splitting were to be consistently heard, it would indicate difficulty with the pulmonary valve closing and suggest pathology. Because this is a normal finding no referrals need to be made.
The nurse brings a 2-day-old newborn into the mother's room in the postpartum unit. The mother voices concern that the newborn's hands and feet "look a little blue." Which response by the nurse is best? "New moms often worry that something is wrong. Everything is fine." "This is normal for a newborn. You do not have anything to worry about." "This condition is known as acrocyanosis. It is normal for a newborn, but I will be sure to let the pediatrician know." "This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."
D Blueness of the hands and feet, known as acrocyanosis, is normal in newborns up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life.