Ch. 31 - Assessing Children and Adolescents
Normal pulse rate (10 years-adult):
55-90 bpm
Normal pulse rate (2-10 years):
70-110 bpm
Normal pulse rate (3 months-2 years):
80-150 bpm
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? A. Measure height while recumbent B. Calculate and plot body mass index C. Measure abdominal circumference D. Weigh child using a stadiometer
A
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. A. True B. False
A
A nurse recognizes that what observation is most important to provide clues as to a child's overall health? A. Behavior B. Alteration in vital signs C. Height in the 5th percentile for age D. Lack of eye contact with the examiner
A
A nurse should keep in mind what principle of development when interviewing a school-age child? A. Visual aids will help to explain the process B. Egocentric thought is present C. Involve the child in the planning D. Use simple explanations
A
A teenage client shows symptoms of human papillomavirus during a health surveillance visit. What is the first action the nurse should take to educate the client about the condition? A. Reassure the client that findings will remain confidential B. Recruit the help of the client's parents C. Explain how girls are more susceptible to sexually transmitted infections (STIs) D. Describe all the risks of unprotected sex
A
After completing a developmental assessment, the nurse determines that a 3-year-old client is following normal developmental patterns. What did the nurse assess in this client? A. Talks using complete sentences B. Talks with two to three words C. Talks using two to three word phrases D. Defines words
A
The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate? A. Denver Developmental Screening B. Apgar Scoring C. Hirschberg Screening D. Blackboard Screening
A
The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding? A. This is a normal finding for a toddler. B. The toddler may have worms. C. The toddler may have an intestinal obstruction. D. The toddler may have toxic megacolon.
A
The nurse is performing an assessment on a toddler. What finding would be expected? A. Visual acuity 20/200 B. Visual acuity 20/20 C. Visual acuity 20/30 D. Visual acuity 20/70
A
The nurse is planning a presentation on childhood growth and development to a group of new parents. Which of the following should the nurse include in the teaching plan? A. A child's head reaches 90% of its full growth by 6 years of age. B. Half of a child's postnatal brain growth is achieved by 3 years of age. C. During the school-aged years, the cranium grows faster than the face. D. Lymphoid tissue reaches adult size by 4 years of age.
A
The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to A. hop on one foot. B. skip a rope. C. throw a ball. D. balance on alternate feet with eyes closed.
A
The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child? A. On the parent's lap B. On the examination table C. Stool D. Standing
A
The nurse should assess which female client for signs of increased ovarian hormone secretion? A. a 9-year-old B. a 17-year-old C. a 45-year-old D. a 60-year-old
A
Upon assessment of the child's eyes, they deviate inward. The nurse recognizes this as what? A. Esophoria B. Exophoria C. Farsightedness D. Nearsightedness
A
What care should a nurse take to encourage the adolescent to communicate during the health assessment interview? A. Use open-ended and specific questions B. Remain silent and allow the client to talk C. Maintain a friendly approach D. Conduct interview in the presence of client's parents
A
What developmental area does the DDST-II evaluate? A. Personal social B. Education C. Cooperation D. Cognition
A
When examining visual acuity on a 30-month old child, the nurse should assess for what? A. Fixation preference B. "Lazy eye" C. Hyperopia D. Myopia
A
Which assessment finding is commonly observed in clients diagnosed with streptococcal pharyngitis (strep throat)? A. petechiae on the roof of the mouth B. discoloration of the teeth C. thrush noted in the oral cavity D. red, distorted tympanic membrane
A
Which principle of child development should guide the nurse's decisions when planning the assessment of a child to best minimize stress? A. The child's stage of development is a primary factor in the way the child responds to events. B. Environmental factors can affect a child's development and health. C. There is a wide range of behaviors associated with normal child development. D. The physical and social development of a child proceeds along a predictable pathway.
A
While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is A. play. B. direct communication. C. indirect communication. D. closed-ended questions.
A
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? A. Meningitis B. Lymphadenitis C. Esophoria D. Exophoria
A
The nurse is preparing to measure the head circumference of a toddler. The nurse explains to the mother this is important for what reason? Select all that apply. A. It may identify neurological abnormalities B. It can help identify malnutrition C. It is needed to calculate the brain size D. It is an indication of developmental delays E. It indicates how well the child will verbalize as they age
A,B
Which murmur meets the criteria of a innocent murmur? Select all that apply. A. Still B. Pulmonary flow C. Venous hum D. Clicks E. Harsh
A,B,C
The nurse is preparing topics to discuss healthy habits and behaviors with a school-aged client and parents. What will the nurse include in this teaching? (Select all that apply.) A. Healthy meals and snacks B. Use of a car seat C. Avoiding tobacco exposure D. Routine dental examinations E. Avoiding sun exposure
A,B,C,D
Which assessment questions are appropriate when assessing an adolescent? Select all that apply. A. "How would you describe your relationship with your parents?" B. "What do you think is your best characteristic?" C. "What types of food do you like to eat?" D. "What kinds of concerns do your parents have about you?" E. "How are you doing with your schoolwork?"
A,B,C,E
A nurse is assessing the feet and legs of a child with Down's syndrome. Which of the following findings should the nurse expect in this client? Select all that apply. A. Short, broad extremities B. Hyperextensible joints C. Inward positioning of the forefoot, with the heel in normal straight position D. Palmar simian crease E. Twisting of the tibia inward on its long axis F. Adduction of the forefoot and inversion of the entire foot
A,B,D
The triage nurse is assessing a 7 year old child brought to the emergency department complaining of abdominal pain. Which findings would prompt the nurse to have the child evaluated as soon as possible? (Select all that apply.) A. Acute intense pain with vomiting B. Child isolates pain in right lower quadrant C. Diffuse mild pain with no fever D. Child unable to stand due to pain E. Normal gait without facial grimacing
A,B,D
Which characteristics of male maturity are observable in stage 2 of development? A. Pubic hair is long, straight, and only slightly curled. B. Scrotum is somewhat reddened. C. The penis shows enlargement in length. D. Pubic hair is observed primarily at the base of the penis. E. Texture of scrotal skin is changing.
A,B,D,E
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. A. Abdominal pain B. Chest pain C. Leg pain D. Headache E. Neck pain
A,C,D
What strategies can the nurse use when examining the ears of a 4-year-old client? (Select all that apply.) A. Pull the auricle up and back. B. Pull the auricle down and back. C. Insert the speculum .25to .5 inches into the canal. D. Apply minimal pressure. E. Move and pull on the pinna before the examination.
A,C,D,E
A mother visits the clinic for a routine visit with her 5-year-old son. The mother asks the nurse when the child's permanent teeth will erupt. The nurse should explain to the mother that permanent teeth usually begin to erupt by age A. 5½ years. B. 6 years. C. 6½ years. D. 7 years.
B
On assessment, pertussis is identified by what characteristic sign? A. presence of neck rigidity B. a violent cough with a "whoop" sound at the end C. a hollow, machinery-like sounding murmur D. bluish discoloration of the lips
B
The nurse is doing an initial assessment on a school age client admitted to the pediatric unit in sickle cell crisis. When inspecting the eyes, the nurse finds that they are normal. How would the nurse chart these findings? A. Eyes are PERRLA with corneal light reflexes equal bilaterally B. Eyes are PERRLA. EOMs are at 180 degrees. Corneal light reflexes are equal C. Eyes are WNL D. Eyes are PERRLA with EOMs at 180 degrees bilaterally
B
The nurse is preparing to auscultate heart sounds on an 8 year old. Where would the nurse anticipate the point of maximal intensity (PMI)? A. 4th intercostal space B. 5th intercostal space C. 6th intercostal space D. 7th intercostal space
B
The nurse prepares to assess a 7-year-old client. Which approach should the nurse use to support this client's developmental level? A. Use play and praise cooperation B. Maintain privacy and provide a gown C. Provide a doll for play and give choices D. Ensure confidentiality and provide teaching
B
The nurse would suspect appendicitis as the cause of pain if the child pointed to what location? A. Right upper quadrant B. Right lower quadrant C. Left upper quadrant D. Left lower quadrant
B
A 3-year-old child has arrived at the clinic for a physical exam. The nurse should perform which action when completing the growth chart? A. Mark body mass index (BMI) as not applicable on the growth chart. B. Measure height with child in the recumbent position. C. Obtain head circumference and plot results on the growth chart. D. Weigh child using the stadiometer.
C
A child brought to the clinic is observed to have malformed ears. The nurse recognizes that this finding requires what further testing? A. Liver function testing B. Down's syndrome C. Renal function testing D. Deafness
C
A child is repeatedly observed using the hand to push the nose upwards and backwards. What associated physical sign should the nurse assess for? A. thin lips B. a palpable goiter C. discoloration of the lower orbitopalpebral grooves D. Brushfield's spots
C
A nurse is assessing the mobility of the tympanic membrane of a 6-year-old client. Which of the following should the nurse do to correctly perform this assessment? A. Whisper questions from a distance of approximately 8 feet B. Pull the pinna down and back and insert the otoscope C. Direct a puff of air against the tympanic membrane using a pneumatic bulb D. Create a seal by using the smallest speculum that will comfortably fit into the ear canal
C
A nurse is documenting findings for an adolescent client. Which of the following should the nurse do? A. Use terms such as good, poor, and normal B. Use full sentences C. Use a sequential approach D. Use subjective descriptions
C
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. Anal opening is moist and hairless B. Perianal skin tags are present C. A dark ring is present around the anus D. The skin is smooth and without lesions
C
A nurse knows that a visual acuity of 20/20 is achieved at what year of age? A. 2 B. 4 C. 6 D. 8
C
A nurse performs a visual acuity test in a 5-year-old client and finds the vision to be normal. What should the nurse document in the client's records? A. 20/200 B. 20/70 C. 20/30 D. 20/20
C
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? A. Avoid use of interpreters B. Keep a timeline set for interview C. Allow privacy for interview D. Interrupt to clarify issues
C
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 A. the family recently immigrated B. the mother does understand normal growth and development C. the provider is not bilingual D. the mother does bring a translator
C
At what year of age should a nurse expect to observe a child's respiratory rate and pattern change to become like those of an adult? A. 2 to 4 B. 5 to 7 C. 8 to 10 D. 11 to 13
C
How can a nurse help to decrease stress and embarrassment when examining the external genitalia of a young female child? A. Allow the mother to stay in the room with the child B. Place in the lithotomy position and cover with a sheet C. Allow the child to use their hands to spread the labia D. Have the child sit on the edge of the exam table with legs crossed
C
The nurse is assessing a 3-year-old child. The history reveals that the bilirubin level for this child postnatally was 30 mcg/dL. What is the nurse's priority assessment based on this value? A. Blood pressure B. Rectal temperature C. Reflexes D. Kidney function
C
During a routine health supervision visit, the nurse is planning to focus teaching on behaviors and habits with an adolescent client. What topics will the nurse discuss with the client? (Select all that apply.) A. Puberty B. Self-concept C. Nutrition D. Exercise E. Computer screen time
C,D,E
Masses in the adolescent female breast usually indicate
cysts or trauma
Enlargement in adolescent boys suggests
gynecomastia
A child is crying when the nurse enters the examination room. What response should the nurse make in order to minimize the child's distress related to the physical examination? A. Promise the child that the exam "won't hurt." B. Attempt to distract the child by allowing him or her to wear a stethoscope. C. Postpone the exam until the child is less fearful. D. Listen to heart and lung sounds first.
D
A mother of a preschooler asks the nurse what type of toys will promote the child's development. What should the nurse recommend to this parent? A. Board games B. Complex puzzles C. Push-pull toys D. Dress-up clothes
D
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? A. Obtain an order to place the child on a heart monitor B. Ask the mother if the child has a history of cardiac problems C. Turn the child to the left side and listen with the bell of the stethoscope D. Count the apical pulse for a full minute to obtain an accurate rate
D
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? A. Provide information for age-appropriate community activities B. Identify normal findings in the client C. Assess parenting D. Provide information that contributes to an improved state of health
D
At inspection and palpation of a 16-month-old child's head, a nurse finds a third fontanelle between the anterior and posterior fontanelle. Which of the following conditions should the nurse most suspect in this client? A. Hydrocephalus B. Osteoporosis C. Opisthotonos D. Down's syndrome
D
In which anatomic location should the nurse check the apical pulse of an 8-year-old child? A. 4th intercostal space and left of the mid-clavicular line B. 5th intercostal space and at the mid-clavicular line C. 4th intercostal space and at the mid-clavicular line D. 5th intercostal space and right of the mid-clavicular line
D
The nurse determines the heart rate of 100 beats per minute for a 5-year-old client as being: A. Sinus bradycardia B. Evidence of a valve disorder C. Supraventricular tachycardia D. Within normal limits
D
The nurse is caring for an 11-year-old child who was hospitalized after an auto accident. While communicating with this child, the nurse should A. use simple questions. B. provide simple explanations. C. use peers as examples. D. allow the child to engage in the discussions.
D
The nurse is preparing to conduct a physical examination of an 18-year-old client. To support this client's developmental level, how should the nurse approach this assessment? A. With reassurance B. Use a positive attitude C. With nonjudgmental acceptance D. As an adult
D
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 A. magnesium. B. vitamin C. C. zinc. D. iron.
D
While assessing the skin, hair, and nails of a 4-year-old boy, the nurse can anticipate that the child will have A. functioning apocrine glands. B. a thin layer of subcutaneous fat. C. fine, downy hairs on his body. D. smooth-textured skin.
D
While performing cardiac auscultation of a young child, the nurse detects a pulmonary flow murmur that is accompanied by a fixed split second heart sound. What does this suggest? A. Aortic insufficiency B. Tricuspid valve prolapse C. Left-heart volume load D. Right-heart volume load
D
Respiratory rates in adolescent (12-15 years):
12-20
Respiratory rates in school-age (6-11 years):
18-25
Respiratory rates in preschool (3-5 years):
20-28
Respiratory rates in toddler (1-2 years):
22-37
Respiratory rates in infants (<1 year):
30-53
The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age? A. 2 B. 3 C. 4 D. 5
B
A mother visits the clinic with her toddler, who has injured himself in a fall. The nurse caring for the toddler should A. tell the child it is okay to cry in the clinic. B. play a game with the child. C. allow the child to identify the nurse with the parent. D. use demonstrations when providing health teaching to the child.
A
A nurse is observing the throat and tonsils of an 11-year-old girl. Which of the following would represent a normal finding in this client? A. Tonsils twice adult size B. Extension of the frenulum to the tip of the tongue C. Pharyngeal inflammation D. Tonsils not easily seen
A
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? A. Microcephaly B. Macrocephaly C. Separation of cranial sutures D. Normal
A
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? A. Document the finding in the child's chart B. Auscultate lungs for adventitious sounds C. Report the finding to the health care provider D. Percuss to assess for a consolidation
A
A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action? A. Apply oxygen via nasal cannula B. Transport the child for chest x-ray C. Provide reassurance to calm the child D. Encourage prolonged exhalation by having child blow up a balloon
A
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 A. she can begin bowel training as soon as the child appears ready. B. bladder training usually begins at 18 months of age. C. nighttime bladder control is usually achieved by 3 years of age. D. bowel training is usually started when the child is 3 years of age.
A
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 A. stage 2 B. stage 1 C. stage 3 D. stage 4
A
During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child? A. 5 year old B. 7 year old C. 9 year old D. 11 year old
A
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? A. It is likely a breast bud which is a normal finding at this age. B. Is there a history of breast cancer in your family? C. Pubertal changes at age 8 are abnormal and require further evaluation. D. She will likely be prescribed hormonal replacement therapy.
A
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? A. ask the mother to leave the room B. ask the client to change into a gown C. recommend that the mother stay in attendance D. explain that the findings will be discussed at the end of the exam
A
The nurse is assessing a 2-year-old child. What type of abdomen would the nurse expect to find? A. Protuberate B. Flat C. Slightly rounded D. Concave
A
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 A. measles. B. mumps. C. chickenpox. D. tonsillitis.
A
The nurse is collecting the history on a child and discovers that the child has missed a recommended vaccination. What is the nurse's best recommendation? A. Encourage a catch up dose as soon as possible. B. Continue with next scheduled vaccination. C. Suggest receiving missed vaccination after age 18. D. Avoid annual flu vaccine due to missed dose of scheduled vaccine.
A
The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse? A. perianal lacerations extending to external sphincter B. condyloma acuminata in a child older than 3 years of age C. herpes in the anogenital area beyond the neonatal period D. marked dilatation of the anus in knee-chest position
A
The nurse is preparing a teaching session for a group of adolescent high school students. What should the nurse include in this teaching? Select all that apply. A. Methods to prevent pregnancy B. Explanation of how pregnancy occurs C. Expected changes that occur during puberty D. Reason for growth discrepancies between the genders E. Transmission and prevention of sexually transmitted infections
A,B,E
The school nurse understands that which of the following children require the administration of purified protein derivative tuberculin tests to screen for exposure to tuberculosis? (Select all that apply.) A. A child infected with human immunodeficiency virus (HIV) B. A child who traveled to the Midwest United States to visit grandparents for the summer C. A child living in a home with a sister who is an intravenous substance abuser D. A child who moved from a third world country E. A child whose parent is in the military
A,C,D
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? A. Bow-legged B. Unstable gait C. Knock-kneed D. Limps when walking
B
A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect? A. Gynecomastia B. Mastitis C. Precocious puberty D. Trauma
B
A nurse recognizes that which deep tendon reflex is absent in children until the age of 6? A. Biceps B. Triceps C. Brachioradialis D. Patellar
B
A nurse understands that which sleep pattern is considered normal for a preschooler? A. Avoid sleeping in the afternoon B. Sleep 11 to 13 hours per day C. Sleep comfortably without difficulty D. Require only eight to nine and a half hours of sleep
B
A young child refuses to allow a nurse to palpate the abdomen because it tickles. How can the nurse decrease the child's ticklishness to facilitate completion of the exam? A. Speak to the child about the importance of cooperation B. Allow the child to place the hand under the examiner's hand C. Turn the child to the left side and draw up the legs to release tension D. Use the stethoscope to begin, and then slide the hand off when the child is distracted
B
After the age of 2 years, how much do toddlers grow per year? A. About 3 cm B. About 5 cm C. About 7 cm D. About 9 cm
B
As a nurse is examining a 13-year-old boy, she notices a strong body odor. Which developmental change best explains this finding? A. Increased sebaceous gland activity B. Increased apocrine gland activity C. Atrophy of lymph tissue D. Increase in testosterone production
B
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? A. "Can your child spontaneously scribble?" B. "Can your child run, hop, and skip?" C. "Can your child walk up and down steps?" D. "Can your child jump with both feet?"
B
Elevated blood pressure readings in children are most often attributable to what? A. Obesity B. An improperly performed examination C. Diabetes D. An improperly calibrated sphygmomanometer
B
The nurse is assessing a teenage client who has reached puberty. What glands would the nurse know have become active? A. Eccrine B. Apocrine C. Pineal D. Parathyroid
B
The nurse is assessing a young adolescent female client using Tanner Sexual Maturity Rating for Breast Development. The nurse determines that the client has enlargement of the breasts and areolae, with no separation of contours. The client is in Tanner Stage A. two. B. three. C. four. D. five.
B
The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital? A. A 2 year old child is placed in the back car seat. B. An infant is placed in a forward facing car seat. C. A 5 year old child is placed forward facing in a booster seat. D. A 12 year old child is buckled into the front passenger seat.
B
Upon inspection of the external eyes of a child, which position should indicate to the nurse that the eyes are properly located? A. Epicanthal folds partially cover the inner canthus B. Outer canthus aligns with the tip of the pinna C. Corneal reflex is in the same location in both eyes D. Eyebrows are symmetrical in shape over the eyes
B
What does laxity of the soft-tissue structures of the foot cause in young children? A. Pronation B. Pes planus C. Metatarsus adductus D. Talipes calcaneovalgus
B
What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status? A. "Do you ever feel fat or think of yourself as being overweight?" B. "What do you eat in a typical day?" C. "Have you learned to cook yet?" D. "What are your three favorite foods or drinks?"
B
When assessing the ears of a young child, the ears appear malformed. What is the most important assessment related to ear malformation that the nurse should perform? A. Blood pressure B. Urine output C. Bowel routine D. Vision
B
While assessing the head and neck of an 11 year old child, the nurse palpates several tender and swollen lymph nodes. What is the nurse's best action? A. Request further evaluation for possible meningitis. B. Prepare to collect blood to analyze white blood cell count. C. Document the findings and explain that this is normal at this age. D. Tonsils appear pink and small in size.
B
A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention? A. Obtain complete medical history B. Auscultate for heart dysrhythmias C. Raise head of bed and apply oxygen D. Ask for list of current medications
C
A mother brings her 12-year-old son to the clinic for a routine physical. The mother tells the nurse that her son seems to be growing taller recently. The nurse should instruct the mother that the peak growth spurt in boys usually occurs by age A. 12 years. B. 13 years. C. 14 years. D. 15 years.
C
During assessment of a 2 year old child, which assessment by the nurse would best indicate possible hydrocephalus? A. Speech evaluation B. Hearing test C. Head circumference D. Blood pressure
C
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? A. Engages in masturbation and sexual activities B. Pleasure centers on masturbation and genitalia C. Relative sexual indifference and interaction with same-sex peers D. Activity centers on expulsion and retention of body waste
C
The nurse is preparing to assess the heart sounds in a 3-year-old child. To locate the apical impulse, the nurse should plan to place the stethoscope at the child's A. second intercostal space. B. third intercostal space. C. fourth intercostal space. D. fifth intercostal space.
C
The school nurse is assessing vision and hearing for several kindergarteners. At what age does visual acuity approximate that of the adult? A. 1 to 2 B. 3 to 4 C. 5 to 6 D. 7 to 8
C
Your client is a 15-year-old male. His testes and scrotum are enlarged and the scrotal skin is darkened. His pubic hair is coarse and curly but does not extend to the thighs. What Tanner stage would you assign to this client? A. Stage 2 B. Stage 3 C. Stage 4 D. Stage 5
C
The nurse is assessing the motor development of a 3-year-old client. What should the nurse expect to assess in this client? Select all that apply. A. Skip B. Hop on one foot C. Walk up steps with alternating feet D. Stand on one foot for a few seconds E. Walk down steps using alternating feet
C,D
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? A. Prepare client for vaginal and cervical examination. B. Inform the client that her parents must be notified first. C. Obtain urine sample from client. D. Check state regulations about testing and treatment of minors.
D
A mother visits the clinic for a routine visit with her 11-year-old daughter. The mother tells the nurse that her daughter has just started puberty. The mother asks the nurse when she can expect the daughter to begin menstruation. The nurse should explain to the mother that menstruation usually begins about A. 1 year after the onset of puberty. B. 18 months after the onset of puberty. C. 24 months after the onset of puberty. D. 30 months after the onset of puberty.
D
A nurse assesses a child with a large, irregular, macula patch on the face. What is the correct term that the nurse should use to document this finding? A. Café au lait spot B. Hemangioma C. Ecchymosis D. Port wine stain
D
The nurse documents that an adolescent female is in Tanner's stage 4 of pubic hair. What did the nurse most likely assess in this client? A. Sparse, long, straight downy hair B. Darker, coarse, curly but sparse over the mons pubis C. Adult pattern of inverse triangle with growth on the medial thighs D. Dark, curly, and abundant on mons pubis with no growth on medial thighs
D
When assessing the vital signs of a toddler, a nurse records normal temperature, pulse, and respiration, but an elevated blood pressure. What is the initial responsibility of the nurse? A. Report to the physician B. Change the apparatus C. Recheck the blood pressure D. Check for the size of cuff
D
When examining the testicles of a young male child, how can a nurse facilitate the exam without eliciting the cremasteric reflex? A. Perform palpation of both testicles at the same time B. Grasp the scrotum and milk the testicle into the inguinal canal C. Place the child in the knee chest position and keep him warm D. Have the child sit with knees flexed and abducted
D
Children younger than 2 years old should have what measured?
apical rate
Radial pulses may be taken in children over?
two years old