Ch. 27: Children and Adolescents PrepU

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

On the parent's lap

The nurse is assessing a 4-year-old child with complaints of pain and vomiting. Which of the following should the nurse suspect?

Appendicitis

A nurse understands that the frontal sinuses develop at about what age?

7 to 8

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

The nurse is experiencing challenges in eliciting information during the health interview of a 4-year-old boy. How can the nurse best foster communication with the child?

Actively engage the child in play.

A nurse performs a visual acuity test in a five-year-old client and finds the vision to be normal. What should the nurse document in the client's records?

20/30

The nurse assesses the respiratory rate of a 5-year-old boy. Which finding would indicate to the nurse that his rate is within the age-appropriate range for this child?

24 breaths/minute

Which comment during the interview should a nurse recognize as a warning sign that an adolescent is at risk for suicide?

"Books where all the characters die are really cool to read"

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?"

The pediatric nurse is obtaining the nursing history of a 4-year-old girl who is accompanied by her mother. What question should the nurse pose to the child's mother?

"Does your daughter often ask 'why'?" - "why?" is characteristic of preschool development

The nurse is conducting an assessment of Maggie, an 12-year-old child. Which statement by the mother would concern the nurse most?

"Maggie's dresses and shirts don't hang right."

The nurse is assessing the hearing of a 10 year old. Which instruction should the nurse give the child who is undergoing conventional audiometry?

"Raise your hand when you hear a sound."

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?"

When assessing adolescent girls, the nurse should know that what usually appears first?

1) Breast buds -> 2) pubic hair -> 3) axillary hair -> 4) menarche

The nurse is preparing to assess the distance visual acuity of a 5-year-old child. How far from the Snellen chart should the nurse position the child?

10 feet

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child?

5 year old

The nurse is preparing to auscultate heart sounds on an 8 year old. Where would the nurse anticipate the point of maximal intensity (PMI)?

7th intercostal space

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

A 4-year-old boy is brought to the emergency department by his parents, who state that he has been crying and saying his "tummy hurts." Which method would be most appropriate for the nurse to initially assess the problem?

Ask the child to point with one finger where it hurts.

A mother of a 4 year old child calls the clinic nurse because her child has swallowed some type of cleaning agent. What is the nurse's best response?

Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

An infant gains head control before sitting unassisted. The nurse recognizes that this is which type of development?

Cephalocaudal - refers to physical and motor development of the infant from head to toe

A 12 year old adolescent female presents to the clinic alone requesting birth control and testing and treatment suspected chlamydia. What is the nurse's priority action?

Check state regulations about testing and treatment of minors.

A nurse is providing an in-service presentation to a group of new pediatric nurses and reviewing differences in assessment of children and adults. When describing the heart sound typically auscultated in children in comparison to an adult, which characteristic would the nurse describe?

Children typically have higher pitched heart sounds.

Tommy, an 18-month-old, is seen in the clinic for otitis media. The nurse notes that Tommy coos and babbles but does not say distinct words. Which nursing diagnosis is most appropriate?

Delayed growth and development

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

The nurse is assessing a 6-year-old child. While auscultating the child's apical heart rate, the nurse notes that the child's heart rate increases during inspiration. What is the nurse's most appropriate action?

Document this as an expected assessment finding.

The nurse is conducting an assessment of an adolescent. On which areas should the nurse focus a risk assessment and health-related teaching? Select all that apply.

Drug use Suicide Car safety

One of the Healthy People goals for children and adolescents is to reduce the proportion who are overweight or obese. What intervention by the school nurse would help to meet this goal?

Go to each class and give a presentation with discussion of healthy snacking and exercise.

While performing an assessment on a 14 year old, the nurse notes the child has limited range of motion of the neck. The nurse recognizes this could be caused by what?

Meningitis

The nurse obtains the following data about a 3-year-old child during an assessment at the neighborhood health clinic. Which finding would indicate a need for further evaluation of the child?

Has an undescended testes.

Which activity may assist the nurse in assessing the breath sounds of a 5-year-old child?

Have the child blow a pinwheel.

The nurse inspects a 10-day-old infant's umbilicus and notes that it is reddened with the presence of slight discharge. What nursing diagnosis is suggested by these data?

Infection

The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response?

It is likely a breast but which is a normal finding at this age.

The nurse is beginning a physical assessment of a 3-year-old child, who becomes restless and begins to cling to the parent. Which assessment is a priority before the child becomes upset?

Listen to heart sounds.

Which information would a nurse include when taking a health history on a child, but omit with an adult?

Prenatal history

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

A nurse has completed an assessment of a school-age child. The nurse has identified several "soft signs" of potential neurologic impairment. How should the nurse best interpret these findings?

Recognize that the findings may or may not indicate the presence of a neurologic problem.

Which of the following is the most accurate method of determining the length of a child under 24 months of age?

Recumbent length measured in supine position

Which test would the nurse perform to detect the presence of a congenital cataract?

Red reflex - reflex will be absent in the presence of a congenital cataract

The nurse is conducting a health education program on sexual health for adolescents. Which would be inappropriate for the nurse to include?

STI promotion

A 14-year-old girl comes to the clinic and requests to be seen for suspicion of a sexually transmitted disease (STD). What is the nurse's responsibility for treatment of this adolescent?

The nurse understands that it is not necessary to have parental consent to treat an STD in a child 13 years or older.

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.

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

Within normal limits

The nurse completes the health history of a 15-year-old client and the mother. What should the nurse do before beginning the physical examination?

ask the mother to leave the room

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

isolate their pain

The nurse is assessing 16-year-old Michael, who is being seen in the emergency department following an injury on the football field. The nurse asks, "Has Michael been hospitalized before?" Which category of the history and risk assessment does this question reflect?

personal history

After examining the breast development of a 13-year-old girl, the nurse records breast and nipples appear as small mounds with areolar development evident. The appropriate stage of maturity would be

stage 2

A woman who speaks primarily Spanish at home brings her 3-year-old to the clinic for a yearly visit. The mother reports concern that her child's language skills are not progressing as expected. The health care provider may have a difficult time assessing this child's language capabilities if

the provider is not bilingual