Ch 31 Health Assessment Prep U

The nurse is preparing to assess the gross motor development of a 4-year-old child. The nurse should ask the child to balance on alternate feet with eyes closed. throw a ball. hop on one foot. skip a rope.

hop on one foot.

A mother of a 4-year-old asks the nurse when the child will begin to loose his baby teeth. What is the correct response by the nurse? "Baby teeth will begin to be replaced by permanent teeth about age 6 years" "Permanent teeth form earlier in males than they do in females" "Caucasians develop permanent teeth at an earlier age than African Americans" "The age at which permanent teeth begin depends upon when the last baby tooth erupted"

"Baby teeth will begin to be replaced by permanent teeth about age 6 years"

The nurse is examining a 3-year-old girl who becomes distressed during the examination. What should you tell the parents? "This behavior shows inability to adjust." "This behavior shows a lack of discipline." "This behavior is developmentally appropriate." "This behavior is socially inappropriate."

"This behavior is developmentally appropriate."

The school nurse is assessing vision and hearing for several kindergarteners. At what age does visual acuity approximate that of the adult? 1 to 2 5 to 6 3 to 4 7 to 8

5 to 6

During the developmental evaluation, the nurse should utilize the Denver Developmental Screening Test II for which age child? 9 year old 11 year old 5 year old 7 year old

5 year old

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? Lymphoid tissue reaches adult size by 4 years of age. Half of a child's postnatal brain growth is achieved by 3 years of age. During the school-aged years, the cranium grows faster than the face. A child's head reaches 90% of its full growth by 6 years of age.

A child's head reaches 90% of its full growth by 6 years of age.

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 Interrupt to clarify issues Keep a timeline set for interview Avoid use of interpreters

Allow privacy for interview

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? Report to the physician Recheck the blood pressure Change the apparatus Check for the size of cuff

Check for the size of cuff

The nurse identifies the need to assess a child's motor, language and social development. What test would be most appropriate? Denver Developmental Screening Hirschberg Screening Apgar Scoring Blackboard Screening

Denver Developmental Screening

Which finding should cause a nurse concern if found on the interview of a school-age child? Loss of two top deciduous teeth last week Displays difficulty in reading simple sentences Child able to tell the nurse the name of his best friend Mother reports child performs chores around the house

Displays difficulty in reading simple sentences

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? Push-pull toys Complex puzzles Dress-up clothes Board games

Dress-up clothes

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? She will likely be prescribed hormonal replacement therapy. It is likely a breast but which is a normal finding at this age. Pubertal changes at age 8 are abnormal and require further evaluation. Is there a history of breast cancer in your family?

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

What developmental area does the DDST-II evaluate? Education Cognition Cooperation Personal social

Personal social

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? Assess parenting Identify normal findings in the client Provide information that contributes to an improved state of health Provide information for age-appropriate community activities

Provide information that contributes to an improved state of health

A nurse prepares a play room for the children in a pediatric nursing unit. The nurse knows that which type of toys is best suited for toddlers? Push-pull toys Play tents Board games Doctor kits

Push-pull toys

The nurse is conducting a health history with an adolescent patient. What should the nurse explain to the patient about confidentiality? Everything that is discussed will be kept confidential. The only thing that I can share with your parents is if you are sexually active. Since you are a minor, your health history is to be shared with your parents. The only thing that I must share is information that concerns your safety.

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

The nurse is performing an assessment on a toddler and observes a protuberant abdomen. What is the significance of this finding? The toddler may have an intestinal obstruction. This is a normal finding for a toddler. The toddler may have toxic megacolon. The toddler may have worms.

This is a normal finding for a toddler.

A child is repeatedly observed using the hand to push the nose upwards and backwards. What associated physical sign should the nurse assess for? thin lips Brushfield's spots discoloration of the lower orbitopalpebral grooves a palpable goiter

discoloration of the lower orbitopalpebral grooves (The described behavior is frequently associated with perennial allergic rhinitis. Edema and discoloration of the lower orbitopalpebral grooves ("allergic shiners") is also a common characteristic of this disorder. Thin lips are associated with fetal alcohol syndrome. An enlarged thyroid gland (goiter) is not a characteristic of perennial allergic rhinitis but rather of hyperthyroidism. Brushfield's spots, abnormal speckling spots on the iris, suggest Down syndrome)

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 magnesium. iron. zinc. vitamin C.

iron

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 herpes in the anogenital area beyond the neonatal period condyloma acuminata in a child older than 3 years of age marked dilatation of the anus in knee-chest position

perianal lacerations extending to external sphincter

A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that she can begin bowel training as soon as the child appears ready. bowel training is usually started when the child is 3 years of age. nighttime bladder control is usually achieved by 3 years of age. bladder training usually begins at 18 months of age.

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

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 spontaneously scribble?" "Can your child walk up and down steps?" "Can your child run, hop, and skip?" "Can your child jump with both feet?"

"Can your child run, hop, and skip?"

Your patient 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 patient? Stage 4 Stage 5 Stage 3 Stage 2

Stage 4

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? 2 3 4 5

3

After the age of 2 years, how much do toddlers grow per year? About 5 cm About 9 cm About 3 cm About 7 cm

About 5 cm

The nurse should intervene when observing which parental action as a child is placed in a motor vehicle leaving the hospital? A 12 year old child is buckled into the front passenger seat. An infant is placed in a forward facing car seat. A 2 year old child is placed in the back car seat. A 5 year old child is placed forward facing in a booster seat.

An infant is placed in a forward facing car seat.

A young child presents to the emergency department exhibiting intercostal retractions and abdominal breathing. What is the nurse's priority action? Transport the child for chest x-ray Encourage prolonged exhalation by having child blow up a balloon Provide reassurance to calm the child Apply oxygen via nasal cannula

Apply oxygen via nasal cannula (Children in physiological distress compensate with increased respiratory and heart rates. Physiological distress usually results from a respiratory disorder or significant blood loss. (Even children with a known congenital heart problem rarely present in acute distress from ischemic heart disease.) The additional work of breathing is evidenced in a distressed child by nasal flaring accompanied by supracostal, intercoastal, and subcostal chest retractions (Fig. 27.2) or abdominal breathing. <insert Fig. 27.2> Administration of oxygen and support of the child's ability to breathe are the first interventions. Physiological distress is priority to address, then reassurance and efforts to calm the child can be attempted. Oxygen should be applied before a chest x-ray is obtained. Oxygen can be worn during the x-ray. Prolonged expiration is not the priority treatment during acute distress until oxygen is applied and a complete assessment is performed.)

A nurse recognizes that what observation is most important to provide clues as to a child's overall health? Height in the 5th percentile for age Lack of eye contact with the examiner Behavioral changes Alteration in vital signs

Behavioral changes

The nurse is assessing an infant's heart sounds. Erb is best heard at which location? Below tricuspid area Below aortic area Below pulmonic area Below mitral area

Below pulmonic area

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? Bring the child to the emergency department for administration of activated charcoal. Monitor the child closely and bring to the clinic if symptoms appear. Administer ipecac syrup per directions on bottle. Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

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

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? Bring the child to the emergency department for administration of activated charcoal. Administer ipecac syrup per directions on bottle. Monitor the child closely and bring to the clinic if symptoms appear. Call the Poison Help Line #1-800-222-1222 for instructions on treatment.

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

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? Obtain an order to place the child on a heart monitor Count the apical pulse for a full minute to obtain an accurate rate Ask the mother if the child has a history of cardiac problems Turn the child to the left side and listen with the bell of the stethoscope

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

A nurse notes the respiratory rate of a two-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding? Auscultate lungs for adventitious sounds Report the finding to the health care provider Document the finding in the child's chart Percuss to assess for a consolidation

Document the finding in the child's chart

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? She will likely be prescribed hormonal replacement therapy. Pubertal changes at age 8 are abnormal and require further evaluation. Is there a history of breast cancer in your family? It is likely a breast but which is a normal finding at this age.

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

A mother bring her 18 month old toddler to the clinic for a well visit checkup. The nurse perform which action during the child's assessment? Measure height while recumbent Weigh child using a stadiometer Calculate and plot body mass index Measure abdominal circumference

Measure height while recumbent

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 Lymphanitis Esophoria Exophoria

Meningitis

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? Normal Microcephaly Macrocephaly Separation of cranial sutures

Microcephaly

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? Café au lait spot Hemangioma Ecchymosis Port wine stain

Port wine stain (A port wine stain is a birthmark consisting of capillaries that may darken with exertion or increases in temperature. It appears as a large, irregular, macula patch on the face or scalp. It does not fade with time. A café au lait spot is a light brown, round or oval patch. A hemangioma is caused by an increased amount of blood vessels in the dermis of the skin. Ecchymoses is another name for bruising and may indicate abuse.)

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? Document the findings and explain that this is normal at this age. Prepare to collect blood to analyze white blood cell count. Request further evaluation for possible meningitis. Tonsils appear pink and small in size.

Prepare to collect blood to analyze white blood cell count.

A nurse understands that which sleep pattern is considered normal for a preschooler? Avoid sleeping in the afternoon Sleep 11 to 13 hours per day Sleep comfortably without difficulty Require only eight to nine and a half hours of sleep

Sleep 11 to 13 hours per day

Which characteristics of male maturity are observable in stage 2 of development? SELECT ALL THAT APPLY The penis shows enlargement in length. Pubic hair is long, straight, and only slightly curled. Pubic hair is observed primarily at the base of the penis. Texture of scrotal skin is changing. Scrotum is somewhat reddened.

Pubic hair is long, straight, and only slightly curled. Pubic hair is observed primarily at the base of the penis. Scrotum is somewhat reddened. Texture of scrotal skin is changing.

A child presents to the emergency department with nasal flaring and intercostal retractions. What is the nurse's priority intervention? Obtain complete medical history Raise head of bed and apply oxygen Ask for list of current medications Auscultate for heart dysrhythmias

Raise head of bed and apply oxygen

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage? Engages in masturbation and sexual activities Pleasure centers on masturbation and genitalia Activity centers on expulsion and retention of body waste Relative sexual indifference and interaction with same-sex peers

Relative sexual indifference and interaction with same-sex peers

During the health assessment interview, a nurse should ask the parents of a 9-year-old male questions related to which activities to elicit age-related development of psychosexual stage? Relative sexual indifference and interaction with same-sex peers Engages in masturbation and sexual activities Activity centers on expulsion and retention of body waste Pleasure centers on masturbation and genitalia

Relative sexual indifference and interaction with same-sex peers

A child brought to the clinic is observed to have malformed ears. The nurse recognizes that this finding requires what further testing? Liver function testing Down's syndrome Renal function testing Deafness

Renal function testing

The nurse would suspect appendicitis as the cause of pain if the child pointed to what location? Right upper quadrant Right lower quadrant Left upper quadrant Left lower quadrant

Right lower quadrant

On assessment, pertussis is identified by what characteristic sign? a violent cough with a "whoop" sound at the end a hollow, machinery-like sounding murmur presence of neck rigidity bluish discoloration of the lips

a violent cough with a "whoop" sound at the end

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 provide simple explanations. allow the child to engage in the discussions. use peers as examples. use simple questions.

allow the child to engage in the discussions.

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? explain that the findings will be discussed at the end of the exam recommend that the mother stay in attendance ask the client to change into a gown ask the mother to leave the room

ask the mother to leave the room

While communicating with an ill 5-year-old child, one of the most valuable communication techniques that the nurse can use is indirect communication. play. direct communication. closed-ended questions.

play

A nurse finds that a 14-year-old girl's breasts are red, edematous, and tender. Which of the following conditions should she suspect? Trauma Gynecomastia Precocious puberty Mastitis

mastitis

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 tonsillitis. chickenpox. measles. mumps.

measles

The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse? marked dilatation of the anus in knee-chest position condyloma acuminata in a child older than 3 years of age herpes in the anogenital area beyond the neonatal period perianal lacerations extending to external sphincter

perianal lacerations extending to external sphincter (

Which assessment finding is commonly observed in clients diagnosed with streptococcal pharyngitis (strep throat)? thrush noted in the oral cavity red, distorted tympanic membrane discoloration of the teeth petechiae on the roof of the mouth

petechiae on the roof of the mouth

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 1 stage 4 stage 2 stage 3

stage 2

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. False /True

true