Chapter 31: Assessing Children and Adolescents

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

hop on one foot. Four-year-old children can skip, hop on one foot, catch a ball, and go downstairs using alternate feet.

The nurse is assessing a teenage client who has reached puberty. What glands would the nurse know have become active? Apocrine Eccrine Parathyroid Pineal

Apocrine Apocrine (sex) glands become active at puberty. Eccrine, pineal, and parathyroid have been active since birth.

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

Check for the size of cuff The initial responsibility of the nurse is to check for the cuff size because a too small cuff may lead to a false rise in blood pressure and a large cuff may lead to a false decrease drop in blood pressure. Reporting to the physician, rechecking of the blood pressure, and changing the apparatus are appropriate interventions, but after checking the cuff size.

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? Report the finding to the health care provider Document the finding in the child's chart Percuss to assess for a consolidation Auscultate lungs for adventitious sounds

Document the finding in the child's chart The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute. The nurse should record this normal finding in the child's chart.

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

Mastitis Redness, edema, and tenderness in the breasts indicate mastitis. Enlargement of the breasts in adolescent boys suggests gynecomastia. Masses in the adolescent female breast usually indicate cysts or trauma. Breast development before age 8 may indicate precocious puberty or thelarche.

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? Separation of cranial sutures Macrocephaly Microcephaly Normal

Microcephaly HC not within the normal percentiles may indicate pathology. A finding greater than 95% may indicate macrocephaly. A finding under the 5th percentile may indicate microcephaly. Increased HC in children older than 3 years may indicate separation of cranial sutures due to increased intracranial pressure.

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 vitamin C. magnesium. iron. zinc.

iron. Concave shape, "spoon nails" (koilonychia) indicate iron deficiency anemia.

The nurse is assessing the heart rate of a 5-year-old client. The client's heart rate is assessed at 100 beats per minute at rest, which the nurse determines as which of the following? evidence of a valve disorder supraventricular tachycardia within normal limits sinus bradycardia

within normal limits The average heart rate of a 5-year-old client at rest is 103 beats per minute, with the range being from 68 to 138 beats per minute. Sinus bradycardia is a heart rate less than 60 in a 5-year-old client at rest. A heart rate of 100 beats per minute in a 5-year-old client at rest is not evidence of a valve disorder. A resting heart rate of up to 240 beats per minute would be assessed in supraventricular tachycardia.

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

"Can your child run, hop, and skip?" The most appropriate question for the parents of a preschooler would be to ask if the child can run, hop, and skip. Running, hopping, and skipping indicate the level of motor development in the child. The nurse need not ask the parents if the child can scribble, because at 15 months the child can spontaneously scribble. Parents of a toddler should be asked if their child can walk up and down the steps and jump with both feet.

A 16-year-old child states to the school nurse, "I don't know what to do. My friend and I went to the movies the other night and he drank several beers. I was scared to ride home with him. What should I do if this happens again?" What is the best response by the nurse? "Don't get in the car with him anymore. He's showing signs of becoming an alcoholic." "It's your friend. He would never do anything to hurt you." "How far did you have to ride home?" "Have the number of a responsible adult whom you can call to drive you home if this should happen again."

"Have the number of a responsible adult whom you can call to drive you home if this should happen again." The nurse can provide scenarios in which the adolescent has alternatives to riding with an impaired driver. He or she should encourage the use of a designated driver if the teen is in a situation in which he or she anticipates drinking or drug use.

A nurse is assessing the moral development of an 11-year-old-child. The nurse determines normal moral development has been achieved when the parents make which of the following statements? "Our child is always trying to please us." "We use distraction to prevent our child from doing dangerous things." "It's like our child does not know what is right or wrong." "Our child is a handful, always getting into trouble."

"Our child is always trying to please us." Between the ages of 10 and 13 years of age, children are at the conventional level of Kohlberg's moral development theory. The school-age child wants to please and conform to social norms. If a school-age child is not conforming and is always getting into trouble, they have not met the conventional level. Knowing what is morally right and wrong occurs at the postconventional level of morality during adolescence (13 and older). Distraction to prevent injury is used with toddlers who are in the substage of the preconventional stage, which involves punishment and reward.

A nurse performs a physical assessment on a 5-year-old child. The nurse auscultates a split S2 heart sound, vital signs are all within normal limits, and the child appears healthy. The parents become anxious and ask the nurse, "What does a split S2 heart sound indicate?" How should the nurse respond to the child's parents? "Split S2 heart sounds are common in some children." "This is an abnormal finding. We will need to place an emergency consult for a cardiologist." "I would be worried if your child had an S3 heart sound but not an S2." "All children have split S2 heart sounds. It resolves as they age."

"Split S2 heart sounds are common in some children." Split S2 heart sounds are common in some (but not all) children. An S3 heart sound would not be cause for concern; it is also normal in some children. The nurse does not need to place an emergency consult for a cardiologist because the child appears healthy and split S2 heart sounds are normal in some children.

What question should the nurse ask in order to assess an adolescent's risk factors for obesity and deficient nutritional status? "What are your three favorite foods or drinks?" "What do you eat in a typical day?" "Do you ever feel fat or think of yourself as being overweight?" "Have you learned to cook yet?"

"What do you eat in a typical day?" Describe what you eat on an average day. Overweight and obesity have serious health consequences among children and adolescents, including a greater risk of high cholesterol, hypertension, and diabetes mellitus.

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. Expected changes that occur during puberty Transmission and prevention of sexually transmitted infections Reason for growth discrepancies between the genders Explanation of how pregnancy occurs Methods to prevent pregnancy

- Transmission and prevention of sexually transmitted infections - Explanation of how pregnancy occurs - Methods to prevent pregnancy The period of adolescence is one of renewed sexual interest. The nurse should focus on teaching that addresses sexual issues such as prevention of pregnancy, how pregnancy occurs, and what can be done to prevent the transmission and development of sexually transmitted infections. Changes that occur in puberty and the reasons for growth discrepancies between the genders is teaching appropriate for the school-age child.

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

Sleep 11 to 13 hours per day

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 A 4-year-old child is generally talkative and engaged in the visit and can answer simple questions about self and concerns . Listen for speech difficulties. By 2 years of age, the child uses two-word sentences; by 3 years of age, a child should speak in more complicated sentences with speech that is understandable 75% or more of the time.

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

5 year old The Denver Developmental Screening Test II (DDST-II) (Frankenburg, Dodds, Archer, Shapiro, & Bresnick, 1992) is one of several standardized developmental screening tests used in the examination of the child and required for early and periodic screening and developmental testing. The DDST-II is considered the standard criterion for the developmental evaluation of children aged 1 month to 6 years. It evaluates four developmental areas of interest: personal/social, language, fine motor/adaptive, and gross motor.

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 6½ years. 5½ years. 7 years. 6 years.

6 years. Permanent teeth begin forming in the jaw by age 6 months and begin to replace temporary teeth at age 6 years, usually starting with the central incisors.

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? Speak to the child about the importance of cooperation Allow the child to place the hand under the examiner's hand Turn the child to the left side and draw up the legs to release tension Use the stethoscope to begin, and then slide the hand off when the child is distracted

Allow the child to place the hand under the examiner's hand To decrease ticklishness, have the child help by placing the hand under the nurse's hand, using age-appropriate distraction and conversation focused on something other than the exam.

A parent brings their toddler (2 years old) to the clinic for a regular screening. What approaches should the nurse use to assess a toddler? Use storytelling or puppet play to engage the toddler. Ask the parent to leave the room. Allow the toddler to sit on the parent's lap during the examination. Explain procedure and allow toddler to manipulate the equipment.

Allow the toddler to sit on the parent's lap during the examination. According to Erikson's psychosocial development theory, toddlers are attempting to achieve trust versus mistrust. Allowing the toddler to stay on the parent's lap will lessen the toddler's anxiety because the parent is trusted. The nurse would explain the procedure to a school-aged child and allow them to manipulate the equipment, like the blood pressure cuff or stethoscope. Storytelling and puppet play are used with preschool-age children. The nurse would not ask the parent to leave the room, because this would increase the child's anxiety.

When assessing adolescent girls, the nurse should know that what usually appears first? Breast buds Menses onset Pubic hair Axillary hair

Breast buds Breast development occurs first. This is followed by the growth of pubic hair, axillary hair, and then menarche.

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? Obtain urine sample from client. Inform the client that her parents must be notified first. Check state regulations about testing and treatment of minors. Prepare client for vaginal and cervical examination.

Check state regulations about testing and treatment of minors. Most states permit contraception and treatment for sexually transmitted infections at 13 years of age; therefore the nurse should first check state regulations regarding a 12 year old seeking treatment before collecting urine sample or cervical exam is performed.

A nurse auscultates the heart rate in a young child and notes an irregular rhythm. No other abnormal vital signs are present and the child is not in any distress. What is an appropriate action by the nurse in regards to this finding? Count the apical pulse for a full minute to obtain an accurate rate 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 Obtain an order to place the child on a heart monitor

Count the apical pulse for a full minute to obtain an accurate rate An irregular heart rate in an otherwise stable child is most often a sinus arrhythmia and does not require intervention. The nurse should count the apical pulse for a full minute to obtain an accurate heart rate.

A nurse reviews the vital signs of a 1-year-old client: Temperature: 98.6° F (37° C), pulse 135 beats per minute, respiratory rate 30 breaths per minute. What is the best action of the nurse? Document findings. Reassess pulse. Ask another nurse to reassess the respiratory rate. Report abnormal findings.

Document findings. Because the vital signs are within normal range, the nurse would document the findings. Normal vital signs for a 1-year-old include temperature 98.6° F (37° C), pulse for 3-month-old to 2-year-old is 80 to 150 beats per minute, respiratory rate from ages 1 to 2 years is 22 to 37 breaths per minute. Because these are normal signs the nurse does not need to report the findings, reassess the pulse, or ask another nurse to reassess the respiratory rate.

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 bud 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? She will likely be prescribed hormonal replacement therapy.

It is likely a breast bud which is a normal finding at this age. Breast development begins with a "breast bud" or enlargement of the areola followed by enlargement of breast tissue. The onset of pubertal changes before 8 years in girls and 9 years in boys may be too early and needs further evaluation.

The nurse is preparing to perform an assessment on a toddler. Where should the nurse position the child? Standing On the examination table On the parent's lap Stool

On the parent's lap A toddler can remain in the parent's lap to decrease anxiety. An examination table may increase anxiety, a stool is not safe and a toddler will not remain inactive long enough to stand

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 The most pertinent intervention is to provide information that contributes to an improved state of health. Parenting would be assessed throughout childhood but is not the most appropriate intervention for a pre-teen client with pneumonia. Age-appropriate community activities are not a concern for a client with a respiratory infection.

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? Board games Doctor kits Play tents Push-pull toys

Push-pull toys The nurse should keep push-pull toys for the toddlers in the play room because toddlers play alongside and engage in locomotive play. Play tents and doctor kits are ideal for preschoolers because they engage in interactive and associative play. Board games are ideal for school-age children because they engage in competitive play.

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? Pleasure centers on masturbation and genitalia Engages in masturbation and sexual activities 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 School-age children who are in the latency period of the psychosexual development stages have sexual indifference and tend to interact with same-sex peers. In a preschooler, pleasure is centered on masturbation and genitalia. Adolescents engage in masturbation and sexual activities with others. In toddlers, the erogenous zones are the anus and buttocks, and their activities are centered on expulsion and retention of body waste.

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? Stage 5 Stage 2 Stage 4 Stage 3

Stage 4 Stage 4: Pubic hair, coarse and curly hair, as in the adult; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs. Penis, further enlarged in length and breadth, with development of the glans. Testes and scrotum, further enlarged; scrotal skin darkened.

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

The only thing that I must share is information that concerns your safety. The nurse should never make confidentiality unlimited and will need to act on information that threatens the client's safety. The health history is not to be shared with the parents, including sexual activity.

The nurse manager in a pediatric clinic should intervene when observing which assessment technique by a staff nurse? Pulling the pinna up and back in a 6 year old child. Using the pneumatic bulb while trying to visualize the tympanic membrane Pulling the pinna down toward the face in an 8 month old infant. Pulling the pinna straight back in a 2 year old child.

Using the pneumatic bulb while trying to visualize the tympanic membrane Once you have visualized the membrane, use the pneumatic bulb to test for movement of the tympanic membrane, not while trying to visualize the membrane. As head shape changes, visualization of the tympanic membrane requires alterations in technique. In the child younger than 1 year, pull the pinna down and toward the face to straighten out the ear canal and promote visualization of the tympanic membrane. In the child 1-2 years of age, pull straight back on the pinna to straighten the ear canal for visualization of the tympanic membrane. After 2-3 years of age, pull up and back on the top of the pinna to visualize the tympanic membrane.

The nurse determines the heart rate of 100 beats per minute for a 5-year-old client as being: Evidence of a valve disorder Within normal limits Supraventricular tachycardia Sinus bradycardia

Within normal limits The average heart rate of a 5-year-old client is 103 beats per minute, with the range being from 68 to 138 beats per minute. Sinus bradycardia is a heart rate less than 60 in a 5-year-old client. A heart rate of 100 beats per minute in a 5-year-old client is not evidence of a valve disorder. A heart rate of up to 240 beats per minute would be assessed in supraventricular tachycardia.

The nurse is performing a cardiopulmonary assessment on a 6-year-old client. Which finding would cause the nurse to anticipate treatment for pertussis? bluish discoloration of the lips a hollow, machinery-like sounding murmur presence of neck rigidity a violent cough with a "whoop" sound at the end

a violent cough with a "whoop" sound at the end Pertussis is respiratory disorder characterized by a paroxysmal cough with a "whoop" at the end. Meningitis is associated with nuchal rigidity. A hollow, machinery-like murmur is heard in clients with patent ductus arteriosus. Bluish discoloration of the lips is associated with generalized cyanosis.

The nursing is preparing to assess a 5-year-old client. Which principle of child development should guide the nurse's decisions when planning the assessment? ensuring a comfortable, confidential environment for the client understanding the client's progression from concrete to formal operational thinking ascertaining the client's approximate developmental level recognizing that the client may be preoccupied with physical changes in the body

ascertaining the client's approximate developmental level The nurse should ascertain the client's approximate developmental level when preparing for the exam. Adolescents are expected to progress from concrete to formal operational thinking, which is more advanced than the developmental stage expected for the 5-year-old client. The key to successfully examining adolescents, not a 5-year-old client, is providing a comfortable and confidential environment; for a 5-year-old client, parents are usually watching and taking part in the interaction. Similarly, being preoccupied with physical changes in the body is characteristic of the adolescent client.

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

play Play is one of the most valuable communication techniques when working with children; it allows for the discovery of important clues to children's development and illness behaviors.

The nurse is going to examine a child with suspected sexual abuse. What piece of data would be a strong indicator of sexual abuse? condyloma acuminata in a child older than 3 years of age perianal lacerations extending to external sphincter herpes in the anogenital area beyond the neonatal period 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 bowel training is usually started when the child is 3 years of age. bladder training usually begins at 18 months of age. nighttime bladder control is usually achieved by 3 years of age. she can begin bowel training as soon as the child appears ready.

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

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 3 stage 2 stage 1 stage 4

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 mother does understand normal growth and development the family recently immigrated the provider is not bilingual the mother does bring a translator

the provider is not bilingual

A nurse is assessing a 2-year-old for achievement of normal developmental milestones. Which of the following skills demonstrates normal cognitive development for a 2-year-old? able to point at an object and make sounds and tones able to identify four or more colors uses two- to three-word phrases possesses 1,500-word vocabulary

uses two- to three-word phrases At the age of 2, toddlers possess a 300-word vocabulary and can state two- to three-word phrases. At the age of 4, a preschooler has a 1,500-word vocabulary. Five-year-old preschoolers are able to state four or more colors. Younger toddlers at the age 15 months use expressive jargon (pointing at objects and making sounds and tones).