test five children

The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to

hop on one foot.

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.

A nurse should implement which important criterion to promote an effective nurse-parent communication when conducting a parent interview as a part of the child assessment?

Allow privacy for interview

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?"

Infant

1 month to 1 year

Toddler

1-3 years

Adolescent

12 to 18 + years

Preschooler

3-6 years

The school nurse is assessing vision and hearing for several kindergarteners. At what age does visual acuity approximate that of the adult?

5 to 6

School-ager

6 to 12 years

A nurse is inspecting the anus of a 5-year-old. Which of the following findings should be a cause of concern for the nurse?

A dark ring is present around the anus

A nurse recognizes that a most valuable communication tool when working with small children is what technique?

Actively engage in play

Separation Anxiety: Nursing Interventions

Adequately prepare child for procedures Hospital bed = "safe area" Reduce Pain Increase control Limit admissions Limit hospital stay Open visiting (include siblings) Primary nursing Use of play

While assessing a young child who appears anxious and afraid of healthcare personnel, the nurse should follow which steps? (Place the nursing actions in the correct order.)

Ask the parent to continue holding the child. Clean stethoscope with alcohol. Listen to heart sounds. Listen to breath sounds. Assess range of motion.

Preschooler pain assesment

Can locate pain Use face scale Fear bodily injury & mutilation Literal

Common Pediatric Illnesses: Impetigo

Cause: Bacterial skin infection, "school sores" Contagious: Highly contagious until sores are healed, or person has been treated with antibiotics for a full 24 hours. Incubation: 1-10 days from the time a person is exposed until symptoms develop. Exclusion: Until child has been treated with antibiotics for a full 24 hours → Change & launder (wash) clothes & linen daily

Common Pediatric Illnesses: Asthma

Cause: Causes airways of lungs to swell & narrow, muscles surrounding airways become tight → decreases amount of air that passes through airway Symptoms: Respiratory distress Cough - with or without sputum Intercostal retractions ("pulling skin between ribs") Wheezing ↑ pulse, anxiety, sweating

Common Pediatric Illnesses: Chickenpox

Cause: Varicella - zoster virus one of the herpes viruses (also causes shingles herpes zoster Contagious 1-2 days before the rash begins until blisters have become scabs

A nurse auscultates the heart rate in a young child and notes an irregular rhythm. No other abnormal vital signs are present and the child is not in any distress. What is an appropriate action by the nurse in regards to this finding?

Count the apical pulse for a full minute to obtain an accurate 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

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

Esophoria

Pain in the Pediatric Patient Infants

FLACC facial expression

Neonate

First 28 days of life

Factors Influencing Growth & Development

Genetics Environment Culture Nutrition Health status Family Caregiver attitudes Child-rearing philosophies

Toddlers pain assesment

Grimace Clench teeth Restless

Education may be focused on:

Growth and development needs Child's health promotion and maintenance as nutritional need and hygienic care. Preventive aspects such as (accident prevention, immunization, periodic examination). Child's illness (nature of illness and care needed). Plan for child's discharge such as child's medication, follow up, nutrition.....etc.

The nurse is preparing topics to discuss healthy habits and behaviors with a school-aged patient and parents. What will the nurse include in this teaching? (Select all that apply.)

Healthy meals and snacks Use of a car seat Avoiding tobacco exposure Routine dental examinations

The nurse is performing education to parents of elementary school children. The nurse tells the parents that the most common symptoms children complain are include what? Select all that apply.

Leg pain Headache Abdominal pain

A mother bring her 18 month old toddler to the clinic for a well visit checkup. The nurse perform which action during the child's assessment?

Measure height while recumbent

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

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

On the parent's lap

Piaget:

Periods of cognitive/Intellectual development

Family Centered Care

Philosophy of care that acknowledges the importance of the family unit as the fundamental focus of all health care interventions Recognizes each family's uniqueness and explain the influence of the family as a constant in the child's life

A pre-teen client has been admitted to the pediatric unit with bilateral lower lobe pneumonia. When writing a plan of care for this client, what would be the most appropriate intervention?

Provide information that contributes to an improved state of health

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

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

Developmental Considerations: Toddlers (1-3 years)

Separation anxiety peaks, seeing the nurse as a stranger increased anxiety: establish trust first Preparation for a procedure should begin immediately before the event Erikson: Psychosocial - 0 to 1 ½ years Trust vs. Mistrust

The nurse is conducting a health history with an adolescent patient. What should the nurse explain to the patient about confidentiality?

The only thing that I must share is information that concerns your safety.

The nurse is examining a 3-year-old girl who becomes distressed during the examination. What should you tell the parents?

This behavior is developmentally appropriate."

Age-specific Approaches to Exam School-age

head to toe, genitalia last, respect privacy

A mother is telling the nurse in a clinic that her family's former doctor told her that her 6-year-old has a venous hum. The nurse knows that this is considered a benign heart murmur at this age.

True

The nurse suspects that a school-age child would benefit from a referral to a health care provider who specializes in the neurologic system. What did the nurse assess to make this clinical determination?

Unstable gait

The nurse manager in a pediatric clinic should intervene when observing which assessment technique by a staff nurse?

Using the pneumatic bulb while trying to visualize the tympanic membrane

Common Pediatric Illnesses: Thrush

Usually in infants (1 st 6 months) r/t naturally have the yeast candida albican in their mouths. Because immune systems are not yet mature, amount of yeast in the mouth can overgrow and lead to an infection. Infant with an infection can develop cracked skin in corners of mouth & whitish or yellowish patches on lips, tongue, or inside cheeks

What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status?

What do you eat in a typical day?"

The nurse is assessing a school age client for a school physical examination. The client is a recent immigrant to the United States; this is the client's first visit to the clinic. When doing the initial assessment, the nurse would assess their nutrition by asking what questions? (Select all that apply.)

With whom do you eat? What food do you eat for the last meal of the day? Is family food prepared at home?

The nurse determines the heart rate of 100 beats per minute for a 5-year-old patient as being:

Within normal limits

Age-specific Approaches to Exam Infant

auscultate heart, lungs first (head-to-toe NOT always appropriate)

School-aged pain assesment

fear disability & death Pain is punishment "Magical quality" of germs Can use faces scale

Age-specific Approaches to Exam Preschool

if cooperative: proceed head to toe, if not, same as toddler

Age-specific Approaches to Exam Toddler

inspect body area through play, introduce equipment slowly

While assessing a 4-year-old child, the nurse observes that the child's nails are concave in shape. The nurse should assess the child for a deficiency of

iron.

It is often difficult to assess the location of pain in a child because generally children cannot

isolate their pain

The nurse is assessing a 4-year-old child with a temperature of 37.7 °C (100 °F). The nurse observes that the client has Koplik spots on his buccal mucosa. The nurse should explain to the client's parents that the child is most likely exhibiting signs of

measles

Kohlberg:

moral development

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

Which assessment finding is commonly observed in clients diagnosed with streptococcal pharyngitis (strep throat)?

petechiae on the roof of the mouth

While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is

play.

Freud:

psychosexual development

A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that

she can begin bowel training as soon as the child appears ready.

Erikson:

stages of psychosocial development