Ch. 23: Health Assessment of Children
The nurse is preparing to obtain anthropometric measurements on a child. The child's mother asks the nurse, "What are these measurements?" Which response by the nurse would be most appropriate? "These measurements are important for school entrance." "They give us information about his muscle strength." "They help us understand how well your child is sleeping." "These are measurements that tell us how your child is growing."
"These are measurements that tell us how your child is growing." RATIONALE: Anthropometric measurements include height, weight, and head circumference and can help determine the child's pattern of growth.
A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction? forward down and back up and back up
down and back RATIONALE: 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 teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education? "Hypoactive bowel sounds are expected in a client with diarrhea." "Bowel sounds will be audible by the naked ear unless distention is present." "You should auscultate all four quadrants for a full minute each." "Bowel sounds should be present within the first few days of life."
"You should auscultate all four quadrants for a full minute each." RATIONALE: During assessment, the nurse should auscultate each quadrant for a full minute when assessing bowel sounds. Therefore, the nurse would include this statement in the teaching. The other statements are inaccurate. Hyperactive bowel sounds are often heard in clients with diarrhea. Bowel sounds should be present within a few hours of life. Bowel sounds are not generally audible with the naked ear.
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. Explain why the technique is incorrect. Counsel the new graduate. Applaud the good technique.
Demonstrate the appropriate technique. RATIONALE: 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. 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.
When assessing the eyes of a toddler, the nurse notes the sclera shows above the pupil. Based on this finding what action should the nurse take? Instruct the mother on eye muscle exercises. Document the finding as normal. Report the finding to the health care provider. Refer the child to an ophthalmologist.
Report the finding to the health care provider. RATIONALE: When assessing the eyes, asses that no sclera shows above the pupil. If it does this is termed "sunset sign." It is a possible indication of increased intracranial pressure or trisomy 21. This finding is abnormal and should be reported to the health care provider. Documenting the finding as normal would be incorrect because the finding is abnormal. The nurse would not refer the child to the ophthalmologist without orders from the health care provider. Eye muscle exercises are not warranted in this situation.
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? Document the finding as normal. Explain to the child's mother that this is normal until about one year of age. Ask the mother if this was a problem in her other children. Report the findings to the physician.
Report the findings to the physician. RATIONALE: Persistent strabismus is normal in newborns. If noted after the age of 6 months it should be evaluated by a pediatric ophthalmologist. This will need to be reported to the physician so that the referral can be made.
Blood pressure monitoring becomes part of the routine health assessment at what age and older? 4 years birth 3 years 1 year 2 years
3 years RATIONALE: Blood pressure monitoring becomes part of the routine health exam at age 3.
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? 1+ 3+ 4+ 2+
4+ RATIONALE: Deep tendon reflexes are graded by the strength of the response using the standard scale from 0 to 4+: 0, no response; 1+, diminished or sluggish; 2+, average; 3+, brisker than average; 4+, very brisk, may involve clonus.
The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation? A gray tympanic membrane A bubble behind the tympanic membrane Visible bony landmarks behind the membrane A mobile tympanic membrane A pearly pink membrane
A bubble behind the tympanic membrane RATIONALE: A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation. The other findings are within normal limits.
The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam? Examine different sections of the body at various times. Examine the child's extremities first and then the chest. Examine the child's chest and then go to the head and down. Examine the child's head and work down to the child's toes.
Examine the child's head and work down to the child's toes. RATIONALE: A preschool or toddler child should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants, the examination starts with the chest, and then proceeds from head to toes.
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal? Five to 10 per minute One to two per minute Sixty per minute Thirty to 40 per minute
Five to 10 per minute RATIONALE: The usual frequency of bowel sounds is 5 to 10 per minute.
The nurse is taking the health history of a 15-year-old client. What would be an appropriate way for the nurse to ask about the client's drug use history? "Some teens like to smoke. Have you tried this?" "Have you smoked crack before?" "Have you smoked cigarettes?" "Have you had alcohol at parties before?"
"Some teens like to smoke. Have you tried this?" RATIONALE: When obtaining a health history from teens, the nurse should approach questions about sensitive subjects in a nonthreatening manner. This method may encourage the teens to not be afraid to ask questions and be more open. The other choices are all direct questions that may make the teen apprehensive or discourage him or her from being truthful when answering.
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. The nurse takes the child's vital signs and height and weight. The nurse observes the general appearance of the child. The nurse interviews the child's caregiver.
The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. The nurse interviews the child's caregiver. RATIONALE: Most subjective data are collected through interviewing the family caregiver and the child. Subjective is the data collected from another source or data that the nurse can not assess, such as pain. No one can feel the pain the client is experiencing. Objective data is information which can be gathered by direct assessment. Getting the necessary information from the caregiver would be a form of subjective data. Taking the vital signs and visual inspection are forms of objective data.
A nurse is reviewing the physical exam of a child. The nurse notes that the child's deep tendon reflexes were normal, because they were graded as: 3+ 2+ 1+ 4+
2+ RATIONALE: The four point grading scale is used in assessing deep tendon reflexes: 4+ is hyperactive, 3+ is brisker than average, 2+ is average, 1+ is diminished, and 0 is no response.
Where is the point of maximal impulse (PMI) found in a 5-year-old child? the fourth intercostal space the third intercostal space the sternum the clavicle
the fourth intercostal space RATIONALE: 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 clavicle is located too high to hear heart sounds.
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 a fontanel (fontanelle). They remain open to allow for rapid brain growth in the first months of life." "The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age." "The soft spots may stay open until your child is 2 or 3 years old." "Soft spots on the child's head should have closed by now."
"The area is called the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age." RATIONALE: The anterior fontanel (fontanelle) typically closes by the age of 9 to 18 months. Fontanels (fontanelles) are soft areas on the skull that remain open in infancy to allow for rapid brain growth in the first months of life. This answer is a true statement but does not answer the mother's question.
A 15-year-old female is being seen for an annual physical examination. The teen asks the nurse if what they talk about will be kept private. What is the appropriate response by the nurse? "Since you are 15 there are some things we can keep private if you wish." "Until you are 16 years of age you will not be afforded total privacy from your parents with regard to your health care concerns." "Privacy is important and I will not share anything we talk about with your parents." "There are some things I may need to share with your parents or physician."
"There are some things I may need to share with your parents or physician." RATIONALE: Teens value privacy. The determination of what may and may not be kept confidential is based on individual state laws. The nurse may need to divulge certain things. It is best to be honest with a teen concerning the privacy of the interview, assessment and care.
The nurse obtains a rectal temperature for an 11-month-old infant. Which action will the nurse perform? Apply water-soluble lubricant to the probe. Continue advancing the probe if resistance is felt. Explain the procedure to the child. Insert thermometer 1.5 inch (3.75 cm).
Apply water-soluble lubricant to the probe. RATIONALE: Applying a lubricant to the thermometer probe will help prevent pain or damage to the rectum. The correct distance to insert a rectal thermometer is no more than 1 in (2.5 cm). Inserting the probe too far can damage or perforate the rectal mucosa. An 11-month-old infant is too young to understand explanation of procedures. If resistance is felt, the nurse should not continue advancing the thermometer probe.
The nurse is assessing a 4-year-old child who reports having ear pain. What would the nurse incorporate into the assessment? Grasp the pinna and pull up and back gently in order to assess the ear. Use diagrams and pictures to explain how the nurse will assess the ear. Avoid having the child see or touch the otoscope prior to the examination. Sit the child on the examination table before examining the child's ears.
Grasp the pinna and pull up and back gently in order to assess the ear. RATIONALE: Because children have short ear canals, it is important to be able to visualize them correctly. Diagrams and charts are more appropriate for a school-aged child. The nurse would enhance cooperation from the child if the parent is holding the child during the examination, rather than having the child sit independently on the examination table. The nurse would encourage the child to play and touch the equipment (otoscope) to decrease fear.
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
Moro RATIONALE: 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. This response should not persist after 4 months of age. The Babinski sign is tested through stimulating the foot/toes. The palmar reflex is tested through the hand/fingers. The root reflex is tested through touch on the corner of the mouth.
A young client is admitted with a fever, vomiting, and diarrhea. Upon taking the health history, the nurse asks the client's parent, "What did you do to help your child before coming to health facility?" This is an example of which type of question? Open-ended Closed-ended Expansive Compound Leading
Open-ended RATIONALE: This is an example of a open-ended question. It allows for the parent to list all the things she did and not limit the response to only one thing or a "yes" or "no." A closed-ended question only gives a person the choice to answer yes or no so it would not give the information needed to make treatment decisions. A compound question is one where a combination of more than one question is asked in a seemingly single question. This type of questioning only causes confusion and may actually provide incorrect information. A leading question is one that prompts a person to answer in a certain way. An expansive question is not asked to gain information. It is generally asked to start the thinking process.
What is typical of a grade II heart murmur? The murmur is soft and hard to hear. The murmur is soft but easily heard. The murmur is loud with an associated thrill. The murmur is loud without an associated thrill.
The murmur is soft but easily heard. RATIONALE: 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.
When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom? localized or generalized color quality amount
localized or generalized RATIONALE: When assessing symptoms such as pain, rashes, or lesions, the location must be assessed for local or generalized. Pain should also be assessed for deep, superficial, or radiating. The other choices describe the quality and quantity of the symptom.
The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? nevus flammeus purpura salmon nevus petechiae
salmon nevus RATIONALE: A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? swollen labia minora labial adhesions lesions on the external genitalia swollen and red anal area
swollen labia minora RATIONALE: 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.
When obtaining information from a teen concerning the reason for seeking health care, which question would be most important? "Do you have any health concerns?" "What health concerns are you having?" "Have you been feeling well lately?" "How long have you been ill?"
"What health concerns are you having?" RATIONALE: When obtaining data from a client, using the appropriate questions is important. Questions should be open-ended to yield the most information. Making questions direct will further refine the information made available. It is important that when interviewing the teen the nurse not promote a condition. Assuming the teen is ill is not appropriate.
A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam? Explain the procedure to the child. Explain that no pain is involved. Allow the child to play with the tuning fork. Demonstrate the procedure on the mother.
Allow the child to play with the tuning fork. RATIONALE: To conduct the Weber test for hearing function the nurse would strike a 500-Hz tuning fork and hold the stem of it against the top of the child's head. The child with normal hearing in both ears will hear the sound equally well with both ears. If the child has an air conduction loss in one ear, the child will hear the sound better in that ear rather than the good ear. The test is used in conjunction with other evaluation tools because if the sound is intensified in one ear, it may mean that there is no hearing perception (i.e., there is nerve loss) in the opposite ear. Explaining and demonstrating the procedure to the child may be important, but developmentally the child needs to be able to see, feel, and hear all equipment being used.
A nurse is assessing a newborn's reflexes. The nurse places his or her thumb to the ball of the newborn's foot to elicit which reflex? palmar grasp parachute plantar grasp Babinski
plantar grasp RATIONALE: Touching the thumb to the ball of the newborn's foot (just below the newborn's toes) would elicit the plantar grasp reflex. The other reflexes are not elicited by this method.
The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment? head and neck; eyes, ears, nose, mouth; then the back and extremities eyes, ears, nose, mouth; back and extremities; then the head and neck back and extremities; head and neck; then the ears, nose, mouth, and eyes back and extremities; eyes, ears, nose, mouth; then the head and neck
back and extremities; head and neck; then the ears, nose, mouth, and eyes RATIONALE: Data are collected by examination of the body systems. Often the exam for an infant is not done in a head-to-toe manner, as is done with adults, but rather in an order that takes the infant's age and developmental needs into consideration. Because the infant is asleep and held against the parent's shoulder, the nurse would begin by assessing the infant's back and extremities. The infant's eyes would be inspected last to allow the infant to be most comfortable until the end of the assessment. Aspects of the examination that might be more traumatic or uncomfortable for the infant are completed last.
A nursing instructor is teaching students how to assess a newborn and emphasizes the importance of taking femoral pulses. Doing so will help to rule out which condition? pulmonary hypertension coarctation of the aorta peripheral disease hypotension
coarctation of the aorta RATIONALE: When performing an assessment on a newborn, it is important to assess the femoral pulse to rule out coarctation of the aorta. The narrowing, or coarctation, of the aorta causes blood to flow to the upper part of the body but not the lower part. The upper half of the body is warm and perfused while the lower is cool and pale. This diagnosis can also be ascertained by B/P readings. If the reading is lower in the leg than the arm then coarctation should be considered. Hypotension would be determined by B/P measurement, not palpating a pulse. Peripheral disease can be arterial or venous in nature. These would be assessed either from the popliteal or dorsal pulses. Pulmonary hypertension is high B/P in the arteries of the lungs. It could not be determined by palpating a peripheral pulse.
The nurse is examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include? Select all that apply. color location size distribution jaundice
color location size distribution RATIONALE: When assessing the skin for lesions or rashes, the nurse would document the location, size, distribution of the lesions over the body, and distinguishing features of the primary or secondary lesion, including color, shape, raised, craterlike or flat, hard or soft if a mass, and exudate. Jaundice is a discoloration of the skin and is not a characteristic finding of a lesion or rash.
The nurse is examining a child and asks the child to show all of the teeth. For which cranial nerve would the nurse be testing? cranial nerve V cranial nerve VII cranial nerve II cranial nerve IV
cranial nerve VII RATIONALE: The nurse would be testing to see if cranial nerve VII was intact. This is the facial nerve and can be tested by asking to see a child's teeth, or having the child smile or lift an eyebrow. In infants facial symmetry would be assessed. Cranial nerve V is tested to determine the muscles of mastication and sensation of light touch on the face. Cranial nerve II assesses the optic nerve. Cranial nerve IV is assessed by having the child follow the light through the six cardinal positions of gaze.
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: teach parent to have child wear hard-soled shoes. refer for further evaluation. document as a normal finding. educate the parent about the abnormal finding.
document as a normal finding. RATIONALE: 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 child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.
A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding? withdrawing the foot from touch dorsiflexion of the newborn's toes curling downward of the toes fanning of the infant's toes
fanning of the infant's toes RATIONALE: A Babinski reflex is part of the neurologic assessment of a newborn. When the newborn is touched or stimulated along the lateral side and ball of the foot, the toes fan.
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? "Come, sit on this pretty, little red chair." "Let's see if I can find some puppies or kittens." "Please sit still so I can see inside your ears." "May I please look inside your ears?"
"Let's see if I can find some puppies or kittens." RATIONALE: The nurse should try to gain the youngster's cooperation by playing a funny pretend game using the "puppies or kittens" to engage the child. It is more likely the preschool-age child would prefer to sit on a parent's lap even though a red chair was offered. Politely asking the child to sit still is respectful but not likely to gain cooperation. Asking permission to look into the child's ear is an invitation for the young preschool-age child to answer "no."
The student nurse is caring for a child who weighs 48 pounds and is 38 inches tall. Which is the child's body mass index (BMI)? 32 33 23 28
23 RATIONALE: The formula used to calculate the English version:(Weight in pounds X 703) ÷ (height in inches X height in inches). The correct calculation equals 23.
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 a: 3-day recall. 12-hour recall. 24-hour recall. 1-week recall.
24-hour recall. RATIONALE: Food intake is best obtained by asking a parent to describe a typical day (24-hour recall), listing what the child ate for each meal and between meals as well.
A nurse taking a health history of a 2-year-old child asks the parent if the child is kept in a playpen or given room to run. What does this question help the nurse learn about the child? The child's well-being and development The child's cognitive level The child's favorite activity The child's IQ
The child's well-being and development RATIONALE: When obtaining a health history, the nurse would assess the child's functional and developmental history. The nurse would assess what type of play the child prefers and where the child plays, types of toys, etc. to help determine functional ability. If a child plays only in the playpen the child is not exploring the world and is only playing with the toys placed in the playpen, not advancing creativity nor developmental skills. The child's IQ and developmental levels would require additional screening/testing that is not included in the health history.
Which physical assessment data would the nurse find concerning and would warrant reporting to the primary care provider? Head circumference is 2 inches less than the chest circumference in a 5-year-old child. a blood pressure of 128/80 in a preschool-aged child an infant who has a closed posterior fontanel (fontanelle) at age 4 months A school-aged child has a heart rate of 90.
a blood pressure of 128/80 in a preschool-aged child RATIONALE: The normal blood pressure for a preschooler is 89-112 systolic and 46-72 diastolic, so a blood pressure of 128/80 is abnormal and needs reporting to the physician. The chest circumference for a child is 2 to 3 inches greater than the head circumference. The normal heart rate for a school-aged child is 60-110. The posterior fontanel (fontanelle) closes around 2 to 3 months of age in infants.
The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action? respiratory rate of 24 breaths per minute heart rate of 89 beats per minute respiratory rate of 20 breaths per minute heart rate of 120 beats per minute
heart rate of 120 beats per minute RATIONALE: The normal range for heart rate for a preschooler is between 65 and 110 beats per minute. The normal range for respiratory rate for a preschooler is between 20 and 25 breaths per minute. A heart rate of 120 would be abnormal.
A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe? bluish coloration of lips and nail beds round flat lesions on the neck black and blue areas on the skin redness of the cheeks and lips
redness of the cheeks and lips RATIONALE: Plethora is used to describe redness of the skin, especially the cheeks and lips. Cyanosis refers to the bluish discoloration of the skin and mucous membranes. Macules are round flat lesions. Ecchymoses are large, diffuse areas of black and blue color.
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? "Do you have a lot of friends at school?" "Would you say that you are a good student?" "Tell me about your favorite activity at school?" "Do you like your school and your teacher?"
"Tell me about your favorite activity at school?" RATIONALE: A good health history includes open-ended questions that allow the child to narrate their experience. The other questions would most likely elicit a yes or no response.
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 and posterior fontanels (fontanelles) Open anterior fontanel (fontanelle) and closed posterior fontanel (fontanelle) Open anterior and posterior fontanels (fontanelles) Closed anterior fontanel (fontanelle) and open posterior fontanel (fontanelle)
Closed anterior and posterior fontanels (fontanelles) RATIONALE: 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 nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading? Were there any side effects from the last immunizations? Do you have the immunization book for us to review? Have you kept the child up to date on all of the immunizations suggested? When did the child have his/her last immunization?
Have you kept the child up to date on all of the immunizations suggested? RATIONALE: A leading question supplies its own answer. This question implies that the child should have had the immunizations and perhaps that the parent is a poor caregiver if he or she gives a different answer than yes. Further, the parent may not be aware of all the current immunizations for the child's age and may inadvertently give an incorrect answer. Asking about the last immunizations is appropriate. Offering to review the immunization record is part of anticipatory guidance. It is important to know if the child had any reactions to the last immunizations to determine whether the child should receive that immunization again.
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 112 beats per minute; respiratory rate 24 breaths per minute Heart rate 100 beats per minute; respiratory rate 18 breaths per minute Heart rate 120 beats per minute; respiratory rate 28 breaths per minute
Heart rate 60 beats per minute; respiratory rate 14 breaths per minute RATIONALE: 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 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. Palpate the skin for texture and hydration status. Auscultate the heart, lungs, and the abdomen. Tap with the knee with a reflex hammer to check for deep tendon reflexes.
Observe the skin for its overall color and characteristics. RATIONALE: The physical examination of children, just as for adults, always begins with a systematic inspection, followed by palpation or percussion, then by auscultation.
The nurse is weighing a 20-month-old child 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 ask the parent to lightly hold the child's hands while the child is sitting on the scale. The nurse should lay the parent on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The nurse should weigh the parent on a standing scale and then weigh the parent again while holding the child.
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. RATIONALE: The child who is able to sit can be weighed while sitting. Keep a hand within 1 in (2.5 cm) of the child at all times to be ready to protect the child from injury. Weighing the parent alone and then holding the child will not provide an accurate weight. Accurate weights are needed for medications and treatments. Holding the child's hands will cause a change in the weight and should not be done.
The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? in the crib on the infant's back in the nurse's own arms in the crib facing the mom
in the crib facing the mom RATIONALE: When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view.
When assisting with the physical exam of a 1-year-old child, the nurse notes the following findings. Which finding would be concerning to the nurse? breaths are counted by observing the rise and fall of the abdomen heart rate of 80 clear drainage coming from the nose ears are aligned with the top of the eyes
heart rate of 80 RATIONALE: The normal heart rate for a 1-year-old infant is 90 to 180 beats per minute, with an average rate of 120 to 130; a heart rate of 80, therefore, is concerning and needs to be reported to the physician. Clear drainage is a common finding in young children and is not concerning. Ear alignment is normal. Health care providers are only concerned when the ears lie below the level of the eye. Abdominal respirations are quite normal for infants.
All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? the center of the forehead to the base of the occiput just above the eyebrows through the prominent part of the occiput the hairline in front to the hairline in back the middle of the forehead through the parietal prominences
just above the eyebrows through the prominent part of the occiput RATIONALE: 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. The measurement is then marked on a growth chart so it can be plotted to assess adequate growth. Each of the other options depicts incorrect placement of the tape for measurement and would not provide a correct measurement of the head.
The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact? eyelid blinks in response to touching the cornea with a wisp of cotton pupil dilation in response to light light of an otoscope reflecting evenly off both pupils pupil constriction in response to light
pupil constriction in response to light RATIONALE: If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment.
The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent? Adolescents will talk more openly if their caregiver is in the same room. Adolescents will share more about themselves in a private conversation. Adolescents will not likely share information related to sexual relationships or to use of substances. Adolescents should be asked if they would like a peer in the room during the interview.
Adolescents will share more about themselves in a private conversation. RATIONALE: All children need the opportunity to actively participate in the health history and assessment process. Adolescents may not feel comfortable addressing health issues, answering questions or being examined in the presence of parents or caregivers. Interviewing them in private often encourages them to share information that they might not contribute in front of their caregivers. Assuring the adolescent that anything shared or discussed will be confidential allows him or her to better discuss sexual needs or use of substances. Adolescents also would rather not have a peer present because they do not want to be seen as different from their peers and there is also the issue of confidentiality.
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? The nurse should encourage the child to act like a big boy and stop hiding. Allow the child to remain "hidden" during the initial part of the interview. Ask the child's mother to pick him up and put him on the examination table. Promise to give the child a small toy or sticker if he will stop hiding.
Allow the child to remain "hidden" during the initial part of the interview. RATIONALE: Children may be shy when at the physician's office. To allow the child the opportunity to initially be "invisible" may be beneficial to help the child become acclimated to the surroundings. Telling the child to act like a big boy is not indicated and may "shame" the child and hinder the development of rapport between the nurse and the child. Eventually the child's mother may need to place him on the examination table but this should not be the initial action by the nurse. Promise of a small token may not work and should not be used at this time.
A 12-year-old client comes to the clinic for an annual checkup. The nurse needs to take a health history and perform a physical exam. Which method would be the most appropriate when obtaining the client's health history? Ask the client if it's OK for the parent to be in the room. Ask the client to fill out the health form. Ask the parent to leave the room. Ask the client to wait outside while the nurse talks with the parent.
Ask the client if it's OK for the parent to be in the room. RATIONALE: When obtaining the health history from a young adolescent, give him or her (aged 11 to 14 years) the choice of whether the parent is present during the interview and examination but always allow time to talk alone with the adolescent. Asking the client to wait outside does not acknowledge the client as a person. Asking the parent to leave the room does not give the client a choice in care. Asking the client to fill out the form is not supportive and does not facilitate an exploration of health history.
A hospitalized child has a pulse oximeter attached to his finger. What interventions would the nurse implement in caring for this client? Check the skin under the probe every 2 hours for tissue perfusion. Change the probe site location every 8 hours. If left on indefinitely, check every 4 hours to ensure that the probe is secure. Check the pulse oximetry alarms at the end of the shift.
Check the skin under the probe every 2 hours for tissue perfusion. RATIONALE: Skin under a pulse oximetry probe needs to be checked every 2 hours to monitor tissue perfusion. Probe sites are changed every 4 hours. Alarms are checked at the beginning of the shift, not at the end. If the child has a continuous pulse oximetry probe, it is checked every 2 hours to be sure the probe is secure.
A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first? Details about the fever Review of systems Family profile History of past illnesses
Details about the fever RATIONALE: When the child has an acute problem, it is important to first obtain the chief complaint. This is the reason the child is brought to the health care provider. The nurse would then ask further questions about the onset, the duration, the characteristics and the course of the problem. The family history, history of past illnesses, and a review of the systems would come later in the process of obtaining the health history.
The registered nurse (RN) will intervene if the unlicensed assistive personnel (UAP) is noted performing which task? obtaining blood pressure reading on a toddler admitted for recurrent urinary tract infections counting the respirations on a preschool-age client for a full minute pulling the earlobe down and back while checking a school-age client's tympanic temperature obtaining an infant's apical pulse while the infant is asleep in the crib
pulling the earlobe down and back while checking a school-age client's tympanic temperature RATIONALE: The RN would intervene if the UAP pulled the earlobe down and back as this is only done when the child is younger than 3 years of age. For a school-age child, the nurse would pull back on the ear. A pulse should be obtained while an infant is resting or asleep to get an accurate reading as the pulse will increase with anxiety. Respirations should be counted for a full minute. Clients younger than 3 years should have their blood pressure monitored if certain risk factors are present, which include recurrent urinary tract infections.
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? "The 95th percentile is not an indication of health." "I will let the physician know that your child is in the 95th percentile for BMI." "Being in the 95th percentile for BMI is not a good thing. Your child is on the verge of obesity. It would be a good idea to consider this with meal planning." "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."
"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." RATIONALE: BMI between the 85th and 95th percentiles for children between the ages of 2 and 20 indicates risk for overweight. BMI greater than the 95th percentile indicates the child is overweight. Informing of the parents of these findings and discussing diet and activity effectively address the issue in a therapeutic way.
When doing a health assessment on a child, the nurse should include a physical assessment. What should the nurse assess first when performing the physical assessment? respirations temperature lung sounds blood pressure
respirations RATIONALE: The assessment of respirations should always be done first. The respiratory rate will change if the child is crying, feeding, or becoming more active. Completing other parts of the physical assessment could influence the count of respirations. When counting respirations, the nurse should be aware that infants use diaphragmatic breathing so the respirations should be counted observing abdominal movements. After 1 year of age breathing changes to thoracic, so chest rise and fall would be used to count respirations. In the sequence of the physical exam, the vital signs would be taken followed by the head-to-toe assessment.
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." "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better." "I used one of those thermometers that goes in the ear, but I don't think it was accurate." "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route."
"My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." RATIONALE: The nurse should address the comment about use of a glass thermometer. These thermometers should be avoided since they contain mercury, which is toxic if the thermometer would break. Tympanic temperature measurement is dependent on several factors, so accuracy is sometimes questionable. Oral electronic thermometers are generally very accurate. Rectal temperatures are usually not necessary due to being invasive.
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? "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." "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 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." RATIONALE: 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. This best response explains why the blueness is occurring without using medical terminology and lets the mother know this is expected and normal. The nurse should not dismiss the mother's concern or decide whether the mother should worry about her newborn.
An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first? Call poison control. Initiate a nasogastric tube. Administer activated charcoal. Determine the type of ingestion.
Determine the type of ingestion. RATIONALE: Utilizing the sense of smell during a health assessment helps the nurse to focus on finding a source for the odor and the potential cause of the odor. When the smell of camphor is present the nurse should evaluate for the ingestion of mothballs. Urine that smells like maple syrup is a symptom of a protein metabolic condition. A sweet smell is associated with a pseudomonas infection. A putrid smell can be associated with fat in the stool from inadequate absorption. Prior to initiating any treatment it is important to find what the child has ingested if at all possible. The poison control center can provide antidotes and treatment protocols for all types of ingestion. The nasogastric tube and/or activated charcoal may or not be needed depending on the type of ingestion that has occurred.
The nurse is performing an assessment of the genitalia of a 15-year-old male. The nurse notes that the pigment of the skin of the scrotum is much lighter than the rest of the client's skin color. What is the nurse's best action? There is no need to address this issue since this is a normal finding for an adolescent male. Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin. Document the findings so there is proof of the assessment findings. Talk with the client's parents to see if they were aware of this pigment issue.
Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin. RATIONALE: While assessment findings do need to be documented, the nurse should ask the client if this finding has always been present because the scrotum is normally darker in color than the rest of the body's skin. The client is old enough to ask him rather than initially speaking with the parents.
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? These lesions will normally fade as the child ages. Once the child has grown these lesions are usually removed by lasers. These lesions are associated with the development of Sturge-Weber syndrome. Biopsies of these areas are usually taken once the child is a teen.
These lesions will normally fade as the child ages. RATIONALE: 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. Nevus flammeus (port-wine stain) are associated with the development of Sturge-Weber syndrome.
At a routine wellness check, the parent of a 6-month-old infant reports concerns about the infant's feet possibly being deformed. The assessment revealed the infant's feet have a mild in-toe position. What information should be provided to the infant's parent? This inward pointing of the toes will likely require bracing once the child begins to ambulate. This bowing inward is problematic but cannot be corrected until the infant is at least 3 years old. This finding is normal for many children; it is the result of positioning in the womb. To correct this problem, there are exercises that can be performed on the infant once the infant is a bit older.
This finding is normal for many children; it is the result of positioning in the womb. RATIONALE: The inward pointing of the toes is normal. It is referred to as metatarsus adductus. It results from positioning of the fetus in the mother's uterus. This is a self-correcting condition. Surgery, braces, and exercises are not indicated at this time.
The nurse collects a client history including biographical data regarding the child being admitted. Which responsibility is most important related to the data collected? The data need to be shared and communicated to the medical and nursing staff. Documentation of the information collected should be done as soon as these data are gathered. This information is part of the legal record and should be treated as confidential. The information collected such as food likes/dislikes and eating habits, should be relayed to appropriate departments in the health care setting.
This information is part of the legal record and should be treated as confidential. RATIONALE: Obtaining a client history—including biographical data (e.g., identifying information about the child, the child's name, address, and phone number, as well as information about the caregiver)—is part of the legal record and should be treated as confidential. Information gathered during the interview should be documented as soon as possible so all members of the interdisciplinary team can participate in the care. All allergies, foods, and food dislikes should be relayed to the appropriate departments but this information is not part of the client demographics.
