PEDS Chapter 10
The nurse is preparing to assess the internal ear structures of a 3-year-old. The child is resistant to the otoscope. How should the nurse respond?
"Let's see if I can find some puppies or kittens."
The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first?
Inspection
Assessing bowel sounds
Inspection Auscultate Percussion Palpate
The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?
Ask the parents to complete a day history.
A nurse realizes the importance of nutritional assessment during the health history. When doing so, the nurse must assess the quality as well as quantity of food eaten. The best way to assess food intake is to do:
24-hour recall.
The nurse is assessing deep tendon reflexes on a child admitted for severe dehydration. The assessment reveals hyperactive reflexes. How should the nurse document this finding?
4+
A nurse is examining the skin of a 15-year-old girl. Which finding would most warrant concern on the part of the nurse?
A very dark mole with an uneven border
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?
Closed anterior and posterior fontanels
The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?
Count after the child stops crying and is comfortable.
The nurse is examining the back and spinal area of a 14-year-old female. A small dimple is noted. What action is most appropriate?
Document the finding as normal.
The nurse is conducting a physical examination of a healthy 6-year-old. Which action should the nurse do first?
Observe the skin for its overall color and characteristics
A nurse is assessing an infant's reflexes. The nurse places his or her thumb to the ball of the infant's foot to elicit which reflex?
Plantar grasp
The nurse is weighing a 20-month-old who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child.
When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested?
The reflex is diminished.
The student nurse is performing an assessment of an infant. Which action by the student nurse requires further instruction by the instructor?
The student nurse asks the parents to step out of the room while performing the assessment
A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. What will the nurse need? Select all that apply.
Thermometer Stethoscope Tongue depressor Ophthalmoscope
When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history?
"Have you heard that some teens like to smoke? Have you tried this?"
The nurse is assessing a newborn child. The mother asks why the newborns feet are blue. What is the best response by the nurse?
"Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body."
The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond?
"For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level."
The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement?
"My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better."
A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his mother. Which statement by the mother should the nurse prioritize for further investigation after noting the father has a history of alcoholism?
"Our next door neighbor is older than my son, and he drinks when they hang out together."
The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor related to taking a temperature?
"Rectal temperatures should not be taken on a child with diarrhea."
The nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information?
"Tell me about your favorite activity at school?"
The nurse is assessing a 6-month-old child. The mother asks when the soft area in her child's head will go away. What is the best response by the nurse?
"The area is called the anterior fontanel and typically closes anytime between 9 and 18 months of age."
The nurse is obtaining a health history on a 10-year-old child and asks the parents about their health history, the health history of their other children, and of their parents' health history. The parents ask the nurse why this information is necessary. What is the best response by the nurse?
"The information can alert us to any disease process that might run in families."
The nurse is preparing to see a 14-month-old child and needs to establish the chief purpose of the visit. Which approach with the parents would be best?
"What can I help you with today?"
When obtaining information from a teen concerning the reason for seeking health care, which question would be most important?
"What health concerns are you having?"
Areas where the sounds of heart valves radiate
A: Aortic valve—second intercostal space, just right of sternum. P: Pulmonic valve—second intercostal space, just left of sternum. T: Tricuspid valve—fourth intercostal space, just left of sternum. M: Mitral valve—fourth intercostal space at left midclavicular line.
The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?
Adolescents will share more about themselves in a private conversation.
A 5-year-old child is being seen at the ambulatory care clinic for a well-child visit. The child is hiding behind his mother. What initial action by the nurse is indicated?
Allow the child to remain "hidden" during the initial part of the interview.
The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. What is the most appropriate way to gather information from the child's caregiver?
Ask the caregiver questions and write the answers down.
The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with complaints of a backache. Which initial action by the nurse is most appropriate?
Ask the child when the pain started.
The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?
Between the sternum and the left nipple
The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam?
Examine the child's head and work down to the child's toes.
The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment?
Place the tape measure around the head just above the eyebrows.
The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated?
Report the findings to the physician.
Assessing skin in children is important as it is a good indicator of their overall condition. What describes cyanosis of the skin?
Skin that is bluish
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?
Take the apical pulse.
The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement or question should the nurse say first to encourage communication?
Tell me about some of your current activities at school.
When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history?
The chief complaint of the child
The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process?
Interviewing the child's caregiver
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?
Five to 10 per minute
What is typical of a grade II heart murmur?
The murmur is soft but easily heard.
The mother of 2-year-old triplets is anxious and worried because one of the trio does not seem to be developing at the same rate as the other two. Which assessment finding would lead the nurse to question the need for further diagnostic testing for this child?
The tops of her ears are below the corners of her eyes.
The nurse is admitting to the intensive care unit a child who arrives on cardiac monitor, pulse oximeter, and an IV infusion. As the nurse begins collecting data on the child, which nursing interventions should the nurse prioritize?
Verify that the alarms on the monitor are still properly set.
How to calculate BMI
Weight in pounds divided height in inches x height in inches - times number by 703
All infants should have their head circumference measured at health-assessment visits. This measurement is made from:
just above the eyebrows through the prominent part of the occiput.
When performing a physical examination on a child, if there is a mirror image in shape, size, and position from one side of the body to the other, the child would have:
symmetry.
