Fall 19/Assessment stuff
Health History Sequence
Biographical Chief Present Past Fam Friends/Envioronment
BMI (body mass index)
Formula: Lb X 704/H X H Underweight - Less than 18.5 Normal - 18.5 - 24.9 - 25 - 29.9 Obese - 30 - 39.9
During an assessment, a child exhibits an audible high-pitched inspiratory noise, a tripod stance and intercostal retractions. Using SBAR communication, the nurse notifies the health care provider and states which breath sounds that are congruent with the clinical presentation of the child? Respiratory stridor Wheezing in the bases Rales in the middle lobe Rhonchi throughout the lung
Stridor is a high-pitched, readily audible inspiration noise that indicates an upper airway obstruction. The child presents in severe respiratory compromise and struggles to breathe. A wheeze is a high-pitched sound heard on auscultation, usually on expiration. It is due to obstruction in the lower trachea or bronchioles. Rales are crackling sounds heard on auscultation when the alveoli become fluid filled. Rhonchi is a snoring sound heard throughout the lung field when inflammation occurs.
The health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer? 1/8 to 1/4 inch (0.32 to 0.64 cm) 1/4 to 1/2 inch (0.64 to 1.27 cm) 1/2 to 3/4 inch (1.27 to 1.91 cm) 3/4 to 1 inch (1.91 to 2.54 cm)
The correct distance to insert a rectal thermometer is 1/4 to 1/2 inch (0.64 to 1.27 cm)
An 18-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should:
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 reflex 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 child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.
