PD CH4

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. How should this action be interpreted?

A way to establish rapport

Which tool measures body fat most accurately?

Calipers

A 5-year-old girl is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. What is the nurse testing for?

Cerebellar function

While caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?

Cheyne-Stokes respirations

Which figure depicts a nurse performing a test for the triceps reflex?

Child elbow bent, hit the back side of the elbow.

What is an appropriate screening test for hearing that can be administered by the nurse to a 5-year-old child?

Conventional audiometry

A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess?

Wheezes

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.)

Elicit one answer at a time., Arrange for the family to speak with the same interpreter, if possible., Introduce the interpreter to the family.

An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?

Explain in simple terms how it works.

A nurse is preparing to assess a 3-year-old child. What communication technique should the nurse use for this child?

Focus communication on child.

Which is the most appropriate vision acuity test for a child who is in preschool?

HOTV chart

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?

Infection or inflammation close to the site

The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what might happen next. Which initial action by the nurse would be most appropriate?

Initiate a game of peek-a-boo.

What is the correct sequence used when performing an abdominal assessment? Begin with the first technique and end with the last. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).

Inspection, Auscultation, percussion, palpation

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?

Introduce self.

The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. What is the rationale for this position?

It prevents cremasteric reflex.

The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. How should the nurse document these findings?

Jaundice

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. How should the nurse assess this diet?

May provide sufficient amino acids

A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?

Murmur

During examination of a toddler's extremities, the nurse notes that the child is bowlegged. What should the nurse recognize regarding this finding?

Normal because the lower back and leg muscles are not yet well developed

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. How should the nurse interpret this finding?

Normal finding

Which is most important to document about immunizations in the child's health history?

Occurrence of any reaction after an immunization

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

Oral mucosa

How does the nurse assess a child's capillary refill time?

Palpating the skin to produce a slight blanching

The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born preterm." This information should be recorded under which of the following headings?

Past history

Where in the health history should the nurse describe all details related to the chief complaint?

Present illness

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action?`

Refer child for further evaluation.

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

Refer for immediate medical evaluation.

Which of the following data would be included in a health history? (Select all that apply.)

Review of systems, Sexual history , Nutritional assessment, Family medical history

A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern?

School-age child

Where is the appropriate placement of a tongue blade for assessment of the mouth and throat?

Side of the tongue

A nurse is preparing to test a school-age child's vision. Which eye chart should the nurse use?

Snellen letter chart

The nurse is using the Centers for Disease Control and Prevention (CDC) growth chart for an African-American child. Which statement should the nurse consider?

The CDC charts are accurate for US African-American children.

What is the single most important factor to consider when communicating with children?

The child's developmental level

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. What criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply.)

The cuff bladder width is approximately 40% of the circumference of the upper arm, The cuff bladder length covers 80% to 100% of the circumference of the upper arm.

Which is most likely to encourage parents to talk about their feelings related to their child's illness?

Use open-ended questions.

What is an important consideration for the nurse who is communicating with a very young child?

Use transition objects, such as a doll.

Which communication technique should the nurse avoid when interviewing children and their families?

Using clichés

What type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

Vesicular

At what age should the nurse expect the anterior fontanel to close?

12 to 18 months

What is the earliest age at which a satisfactory radial pulse can be taken in children?

2 years

Parents of a newborn are concerned because the infant's eyes often "look crossed" when the infant is looking at an object. The nurse's response is that this is normal based on the knowledge that inocularity is normally present by what age?

3 to 4 months

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?

3 to 4 months

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined?

Ask adolescent, "Why did you come here today?"

The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

Ask her, "Are you having sex with anyone?"

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might be most helpful?

Ask the child to draw a picture.

Which approach would be best to use to ensure a positive response from a toddler?

Assume an eye-level position and talk quietly.

A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

85th percentile

Pulses can be graded according to certain criteria. Which is a description of a normal pulse?

+3

A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?

1 to 2 years

At about what age does the Babinski sign disappear?

1 year

Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?

Axillary sensor

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. How should this question be considered?

An important part of the child's past history

The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. How should this action be interpreted?

Appropriate because of child's age

The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?

Are the same

When the nurse interviews an adolescent, which is especially important?

Allow an opportunity to express feelings.

The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school-age child. What is the purpose of doing this?

To measure body fat

A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?

Up and back

Which following parameters correlates best with measurements of the body's total protein stores?

Upper arm circumference

A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child?

Use minimal physical contact initially.