Chapter 32: Health Assessment of Children

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?

"Let's see if I can find some puppies or kittens."

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."

A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his parent. Which statement by the parent should the nurse prioritize for further investigation after noting the father has a history of alcohol use disorder?

"Our next door neighbor is older than my son, and he drinks when they hang out together."

The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature?

"Rectal temperatures should not be taken on a child with diarrhea."

The nurse is obtaining a health history on a toddler and asks the parents about their health history, the health history of their other children, and of their parents' health history. The parents ask the nurse why this information is necessary. What is the best response by the nurse?

"The information can alert us to any disease process that might run in families."

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?

"There are some things I may need to share with your parents or physician."

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 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."

The mother of a 2-year-old asks the clinic nurse why her child's blood pressure is never measured. The mother states, "My blood pressure is measured during each visit to the doctor." What is the best response by the nurse?

"Typically, children younger than 3 don't need blood pressure measured unless they have a serious or chronic condition."

The nurse is preparing to see a 14-month-old child and needs to establish the chief purpose of the visit. Which approach with the parents would be best?

"What can I help you with today?"

A nurse is interviewing a parent regarding the 2-year-old child's recent illness. The nurse would like the parent to elaborate about any symptoms of the illness noticed. Which would be the most effective question for the nurse to ask the parent in this situation?

"What symptoms has your child exhibited?"

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?

"You should auscultate all four quadrants for a full minute each."

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:

2+

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:

24 hour recall

Blood pressure monitoring becomes part of the routine health assessment at what age and older?

3 years

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?

4+

The nurse is caring for a toddler who was just diagnosed with a hearing impairment. What would the nurse expect to assess in the child?

A delay or lack of clear, understandable speech pattern

The nurse is interviewing an adolescent. What should the nurse recognize as an important aspect of interviewing the adolescent?

Adolescents will share more about themselves in a private conversation.

The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with reports of a backache. Which initial action by the nurse is most appropriate?

Ask the child when the pain started.

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.

A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate?

Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed.

The nurse enters a room to perform an assessment and finds the 9-month-old client asleep in the father's arms. Which action will the nurse take first?

Assess the infant's respiratory status.

When preparing to examine a 2-year-old child, which action by the nurse will best establish rapport?

Bend down to the child's eye level to establish contact.

The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?

Count after the child stops crying and is comfortable.

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.

The nurse is performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam?

Examine the child's head and work down to the child's toes.

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?

Five to 10 per minute

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

A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database?

Immunization record

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

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

The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment?

Place the tape measure around the head just above the eyebrows.

A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate?

School age

The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement or question should the nurse say first to encourage communication?

Tell me about some of your current activities at school.

What is typical of a grade II heart murmur?

The murmur is soft but easily heard.

The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply.

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 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 have the child sit on the scale while keeping a hand close to but not touching the child.

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.

The nurse is assessing a 6-year-old child. The nurse instructs the child, "Let me see all of your pretty white teeth." Which cranial nerve is the nurse assessing?

VII

The nurse is conducting a physical examination of a 10-year-old child. The nurse whispers the child's name from behind the child so that the child does not see the nurse's lips moving. Which cranial nerve is the nurse assessing?

VIII

A mother tells the nurse at the clinic she did not bring her child to have his scheduled immunization because the child had a cold. What symptoms are important for the nurse to teach the mother about contraindications for immunizations? Select all that apply.

Wheezing 100ºF (37.8°C) fever for 3 days The child has 102ºF (38.9°C) fever

A nurse is conducting a comprehensive pediatric history of an 8-year-old child. Which data would the nurse likely include? Select all that apply.

age, name, and date of birth developmental milestones allergies to food or medications foods the child likes to eat

The nurse is collecting data on a 9-year-old child being admitted to the pediatric unit. What is the most appropriate way to gather information from the child's caregiver?

ask the caregiver questions and document the answers

While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nurse most likely be performing?

assessing vision

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?

back and extremities; head and neck; then the ears, nose, mouth, and eyes

A nurse is beginning to examine a 4-month-old infant. The nurse takes the infant from the parent's arms and places the infant in which manner?

in the crib facing the parent

To improve the assessment process with a preschool-age child, the nurse will

involve the child in the assessment and allow the child to play with safe medical equipment

When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom?

localized or generalized

The registered nurse (RN) will intervene if the unlicensed assistive personnel (UAP) is noted performing which task?

pulling the earlobe down and back while checking a school-age client's tympanic temperature

A nurse is conducting the health history of a 5-year-old child. Which data would the nurse collect last?

review of systems

When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested?

the reflex is diminished

When obtaining information from a teen concerning the reason for seeking health care, which question would be most important?

"What health concerns are you having?"

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?"

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 the anterior fontanel (fontanelle) and typically closes anytime up to 18 months of age."

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?

Allow the child to remain "hidden" during the initial part of the interview.

The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process?

Interviewing the child's caregiver

The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse

between the sternum and the left nipple

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:

document as a normal finding.

A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction?

down and back