Chapter 34: Child Health Assessment
The nurse is completing initial health assessments for clients being admitted to the acute care facility. Below are the first six (of nine total) sections of an initial health assessment interview. In which order would the nurse complete the documentation? health and family profile history of chief concern/complaint introduction and explanation demographic data day history chief concern/complaint
1. introduction and explanation 2. demographic data 3. chief concern/complaint 4. history of chief concern/complaint 5. health and family profile 6. day history
A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding? a. dorsiflexion of the newborn's toes b. curling downward of the toes c. fanning of the infant's toes d. withdrawing the foot from touch
A Babinski reflex is part of the neurologic assessment of a newborn. When the newborn is touched or stimulated along the lateral side and ball of the foot, the toes fan.
The nurse is performing a health history on a 6-year-old child who is having trouble adjusting to a new school. Which question will elicit valuable information? a. "Do you like your new school?" b. "Are you happy with your teacher?" c. "Do you enjoy reading a book?" d. "What are your new classmates like?"
A careful conversation and interview with the child and/or the caregiver will provide important information about the child's health. Depending on the intent of the health assessment, many of the questions will be direct, and many will require the caregiver or child to answer simply "yes" or "no." In other than emergency situations, though, asking open-ended questions such as "What are your classmates like?" offers an excellent opportunity to learn more about the child's life.
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? a. Demonstrate the appropriate technique. b. Applaud the good technique. c. Explain why the technique is incorrect. d. Counsel the new graduate.
A cremasteric reflex is elicited by stroking the medial aspect of the thigh in boys. With this, the testes move perceptibly upward. The presence of this reflex indicates integrity of the first and second lumbar nerves. Abdominal reflexes should be assessed in both sexes. An abdominal reflex is elicited by lightly stroking each quadrant of the abdomen. Normally, the umbilicus moves perceptibly toward the stroke. Presence of this reflex indicates integrity of the 10th thoracic nerve and the first lumbar nerve of the spinal cord. The new graduate nurse needs to be shown the correct aspect of the thigh to stroke so that she/he can perform the technique correctly in the future. Explaining why the technique is incorrect does not show the nurse how to perform the procedure correctly. The charge nurse would not want to applaud an incorrect procedure, nor is this reason to counsel the nurse.
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. Inability to articulate the sounds of the letter 'R' and "S" when vocalizing b. A delay or lack of clear, understandable speech pattern c. Purulent draining from one or both ears associated with pain behaviors d. A history of supplemental oxygen use at birth or shortly after birth
A hearing impairment will often cause a delay or absence of normal speech and language development in a child. Toddlers typically do not vocalize the sounds of the letter 'R" and "S" until older. Purulent drainage may represent an ear infection. Oxygen at birth may be problematic for vision, but not hearing.
The nurse is assessing symptoms in a 6-year-old child. The nurse knows that symptom assessment includes questioning the child and parent regarding which of the following? Select all that apply. a. location of symptoms b. aggravating or relieving factors c. socioeconomic status d. associated factors or symptoms e. setting in which symptoms occur
All of the answer choices would be part of the assessment of symptoms in a child except for socioeconomic status.
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? a. "What symptoms has your child exhibited?" b. "Has your child exhibited any symptoms?" c. "Has your child exhibited a fever and vomiting?" d. "Your child hasn't exhibited a fever, has she?"
An open-ended question, such as, "What symptoms has your child exhibited?" allows a parent to elaborate, which is what the nurse desires in this case. A closed-ended question, such as, "Has your child exhibited any symptoms?" does not allow the parent to elaborate, and thus would be inappropriate in this case. Compound questions, such as, "Has your child exhibited a fever and vomiting?" should be avoided because the information they elicit is often inaccurate and must be clarified. Likewise, leading questions, such as, "Your child hasn't exhibited a fever, has she?" should be avoided.
A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading? a. Have you kept the child up to date on all of the immunizations suggested? b. Do you have the immunization book for us to review? c. When did the child have his/her last immunization? d. Were there any side effects from the last immunizations?
Answer: a. Have you kept the child up to date on all of the immunizations suggested? A leading question supplies its own answer. This question implies that the child should have had the immunizations and perhaps that the parent is a poor caregiver if he or she gives a different answer than yes. Further, the parent may not be aware of all the current immunizations for the child's age and may inadvertently give an incorrect answer. Asking about the last immunizations is appropriate. Offering to review the immunization record is part of anticipatory guidance. It is important to know if the child had any reactions to the last immunizations to determine whether the child should receive that immunization again.
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? a. "I wish there was a blood test for alcohol use disorder. I know my son is at risk." b. "Our next door neighbor is older than my son, and he drinks when they hang out together." c. "I think I know how my son feels about drinking. He has had substance use disorder education in school." d. "Sometimes my son asks me questions about his father's low tolerance for alcohol."
Answer: b. "Our next door neighbor is older than my son, and he drinks when they hang out together." Some diseases and conditions are seen across families, and this is important in prevention as well as detection for the child. The caregiver can usually provide information regarding family health history. The nurse should use this information to do preventive teaching with the child and family. Early adolescence is a time when experimental use of substances, especially alcohol and tobacco, might be seen. It would be important to assess the use of substances and follow up regarding the behaviors of the adolescent.
As part of a class assignment a nursing student will teach fellow classmates how to conduct a physical assessment on an infant. What priority information should the student teach? a. Have the parent hold the baby to check the ears. b. Complete the assessment in head to toe fashion. c. Assess the heart and lungs first. d. Assess the temperature with tympanic thermometer.
As a rule, assess the heart and lung function first. Conduct the intrusive procedures such as ear and throat assessment last so an infant does not cry and complicate the remainder of the examination. Proper restraint enables an examiner to see well and also to ensure the instrument such as an otoscope will not accidentally cause injury. As a rule, do not ask parents to restrain during any procedures in which the child will feel threatened or feel pain. Parents are best used as protectors and comforters after the exam. Temperatures should be taken temporally.
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels (fontanelles), what should the nurse expect to find? a. Closed anterior fontanel (fontanelle) and open posterior fontanel (fontanelle) b. Open anterior fontanel (fontanelle) and closed posterior fontanel (fontanelle) c. Closed anterior and posterior fontanels (fontanelles) d. Open anterior and posterior fontanels (fontanelles)
By age 18 months, the anterior and posterior fontanels (fontanelles) should be closed. The diamond-shaped anterior fontanel (fontanelle) normally closes between ages 9 and 18 months. The triangular posterior fontanel (fontanelle) normally closes between ages 2 and 3 months.
The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason? a. The number of family members that have a certain health problem will help the nurse know if the child will have the same problem. b. Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. c. The nurse needs to know everything about a family to take care of the child. d. By establishing family behavior, the nurse forces the parents to alter their care of their child and make them healthier.
Collection a complete family health history helps the nurse learn if there certain behaviors or risk factors for the family and, hopefully, educate the family in how to improve both their health and the child's health, as well as reduce the incidence of diseases and chronic conditions.
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: a. 12-hour recall. b. 24-hour recall. c. 3-day recall. d. 1-week recall.
Food intake is best obtained by asking a parent to describe a typical day (24-hour recall), listing what the child ate for each meal and between meals as well.
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? a. Coping strategies of the child b. Past accidents the child was involved in c. Immunization record d. Recent or past hospitalizations
Immunization records are important to know in a health history of any child. If the child is missing any immunizations, the nurse can then educate the parents about vaccines and assist in scheduling immunizations. The other choices are important to know when gathering a history, but the immunization history is the priority in this list.
A nurse is assessing a 3-year-old child in the local health clinic. The child has a persistent cough on examination. Based on the age of the child, which muscle would the nurse view to assess respiratory status? a. Thoracic muscle b. Accessory muscle c. Intercostal muscle d. Abdominal muscle
Infants and children younger than age 6 years typically use their abdominal and diaphragm muscles for breathing. When assessing respiration, the nurse should watch for the abdominal muscles to rise and fall.
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? a. Interviewing the child's caregiver b. Weighing and measuring the child c. Reinforcing teaching with the child's caregivers d. Taking the child's vital signs
Information spoken by the child or family is called subjective data. Interviewing the family caregiver and child allows you to collect information that can be used to develop a plan of care for the child. Collecting objective data would include weighing and measuring the child and taking the child's vital signs. Reinforcing teaching would involve client education to ensure the caregivers are aware of the treatments and/or further care.
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? a. The reflex is brisk. b. The reflex is hyperactive. c. The reflex is diminished. d. The reflex is absent.
On the four-point grading scale used in assessing deep tendon reflexes, 1+ indicates a diminished response. With 2+ as average, a grade of 3+ is brisker than average and 4+ is hyperactive. The reflex is absent at a grade of 0. Healthy children should have reflexes 2+. The newborn has reflexes of 3+ and decreases to 2+ by 3 to 4 months of age
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? a. Infancy b. Preschool age c. School age d. Adolescence e. Young adulthood
Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.
The nurse is examining a 4-year-old who is injured and crying. What might the nurse document about the child's breathing? a. Respirations are slow and shallow. b. tachypnea c. tachycardia d. Respirations are regular.
Tachypnea (rapid breathing or panting) may be observed in a child with fear, anxiety, or stress. Slow, shallow, or regular respirations are normal. Tachycardia is an increased heart rate.
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do? a. Take the apical pulse. b. Count the pulse rate for 30 seconds. c. Use an electronic stethoscope. d. Take a radial pulse.
Taking the apical pulse with a pediatric stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be taken with older children, as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lay close to the skin surface and are easily obliterated. An electronic stethoscope is not necessary to listen to heart sounds and count an apical pulse
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? a. Between the sternum and the left nipple b. Above the sternum, slightly to the right c. Below the ribs about one half of an inch d. Above the clavicle on the left side
When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum. The other locations will not assist with localizing over the apex of the heart.
The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam? a. Convey the impression that there are no right or wrong answers. b. Have the child read each of the 22 words from a sheet of paper. c. Modify the directions of the test using the nurse's own discretion. d. At the end, explain which words the child missed and why.
The Denver Articulation Screening is designed to detect significant developmental delays as well as normal variations in the acquisition of speech sounds. Because it is a standardized test, its directions must be followed precisely, not modified according to the nurse's own discretion. Before the test, explain the child will need to repeat the words she hears you speak. Give enough examples so you are certain she understands what she is to do: "When I say 'boat,' then you say 'boat.'" When you are certain the child understands the directions, say each of the 22 words shown on the Denver Articulation Screening form; do not have the child read the words from a sheet of paper. Convey the impression that there are no right or wrong answers. Give the child approval for responding and following directions correctly, no matter how inaccurately the child repeats the word; the nurse should not explain which words the child missed and why.
Where is the point of maximal impulse (PMI) found in a 5-year-old child? a. the sternum b. the clavicle c. the third intercostal space d. the fourth intercostal space
The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. Up until the age 4 years it is located between the 3rd and 4th intercostal space (ICS). From ages 4 to 6 years it is found at the 4th ICS medial to the left midclavicular line. From age 7 upward it is located at the 5th ICS lateral to the left midclavicular line. Heart sounds radiate and can be heard either to the right or left of the sternum but never directly over the sternum. The clavicle is located too high to hear heart sounds.
The clinic nurse is interviewing a parent about the infant's illness and is in the chief concern part of the health interview. Which question will the nurse ask during this part of the interview? a. "Why did you bring your infant to the clinic today?" b. "What is your infant's date of birth?" c. "How many siblings does your infant have?" d. "Are there any acute or chronic illnesses in your infant's history?"
The chief concern deals with the reason the parent brought the child to the health care agency at this time. Asking "why did you bring your infant to the clinic today" addresses this concern. No other question addresses this concern.
The nurse is taking the health history for a toddler in the emergency department. The child's parent informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection (UTI) 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint? a. Asthma b. Pneumonia c. Vomiting d. UTI
The chief concern/complaint is the reason that the client is seeking current health care and, in this case, is vomiting. The pneumonia, UTI, and asthma are part of the medical history and may or may not have any bearing on why the child is currently sick. These are valid pieces of information and may give the nurse a better picture of the family and child's situation.
A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point? a. Obtaining the health history b. Interviewing the client c. Obtaining biographical data d. Determining the chief complaint
The reason for a visit to a health care setting is called the chief complaint. In a well-child setting, this reason might be a routine check or immunizations, or an illness or other condition. The nurse will obtain this information by interviewing the caregiver. Obtaining the health history and biographical data will also be completed during the assessment process.
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? a. The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. b. The nurse should weigh the parent on a standing scale and then weigh the parent again while holding the child. c. The nurse should ask the parent to lightly hold the child's hands while the child is sitting on the scale. d. The nurse should lay the parent on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight.
The child who is able to sit can be weighed while sitting. Keep a hand within 1 in (2.5 cm) of the child at all times to be ready to protect the child from injury. Weighing the parent alone and then holding the child will not provide an accurate weight. Accurate weights are needed for medications and treatments. Holding the child's hands will cause a change in the weight and should not be done.
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? a. Measure the head circumference routinely on children up to the age of 6 years. b. Place the tape measure around the head just above the eyebrows. c. Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years. d. Place the tape measure around the head with the tape touching just below the eyes.
The head circumference is measured routinely in children to the age of 2 or 3 years, or in any child with a neurologic concern. Place a paper or plastic tape measure around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head. During childhood the chest exceeds the head circumference by 2 to 3 inches.
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: a. document as a normal finding. b. refer for further evaluation. c. educate the parent about the abnormal finding. d. teach parent to have child wear hard-soled shoes.
The infant should be assessed for a Babinski reflex. To achieve this stroke the sole of the foot. Fanning of the toes will occur in infants younger than 3 months of age. A downward reflex of the toes will occur beyond 3 months of age. Some infants will demonstrate a flaring Babinski sign until 2 years of age. In the absence of other neurologic findings this is a normal response. The nurse would document this normal finding. The child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.
The pediatric nurse is performing a head-to-toe exam on a 2-year-old child during a well child assessment. Which method will the nurse use to accurately determine the child's heart rate? a. Palpating the brachial pulse b. Counting the apical rate c. Palpating the femoral pulse d. Calculating the apical rate
The most accurate way of determining the child's heart rate is to count the apical rate by auscultation. The remaining answer choices do not represent the most accurate method to determine the child's heart rate.
The nurse is caring for a child with diarrhea who has a rapidly fluctuating temperature. The nurse obtains an oral temperature and notes the child is febrile, where the child's temperature was within normal limits two hours prior. Which action will the nurse take? a. Obtain a rectal temperature. b. Use a temporal thermometer to verify the reading. c. Compare the reading with an axillary reading. d. Retake the oral temperature to verify the reading.
The temporal thermometer is gaining popularity because it can detect rapid temperature changes. Obtaining a rectal temperature should be avoided if other methods are available, as this may be very distressing to the child and should not be performed if the child has diarrhea. Retaking the oral temperature or comparing the reading with an axillary reading are not the best choices because these do not best detect rapid temperature changes.
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? a. Closed-ended b. Open-ended c. Compound d. Expansive e. Leading
This is an example of a open-ended question. It allows for the parent to list all the things she did and not limit the response to only one thing or a "yes" or "no." A closed-ended question only gives a person the choice to answer yes or no so it would not give the information needed to make treatment decisions. A compound question is one where a combination of more than one question is asked in a seemingly single question. This type of questioning only causes confusion and may actually provide incorrect information. A leading question is one that prompts a person to answer in a certain way. An expansive question is not asked to gain information. It is generally asked to start the thinking process.
A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth? a. Dental caries b. Pinpoint ulcers on the gums c. Reddened mucous membranes d. Loose hardware
When assessing a child with orthodontic appliances such as braces, assess carefully for pinpoint ulcers on the gum line. The cause could be wires that are too tight, causing discomfort or infection. The child should be assessed for dental caries, redness in the mouth and any loose hardware but these are not the priority assessment.
The nurse is taking a respiratory history of a newly admitted child. While documenting the symptoms the child has, what other item is important to document when taking a history on an altered respiratory status? a. The child's weight b. The child's diet c. The child's hospital history d. The triggers in the environment
When assessing a respiratory history, it is very important for the nurse to find out what in the environment worsens the child's symptoms. These are called "triggers." The other choices would be part of a general health history.
A nurse taking a health history of a 2-year-old child asks the parent if the child is kept in a playpen or given room to run. What does this question help the nurse learn about the child? a. The child's favorite activity b. The child's well-being and development c. The child's cognitive level d. The child's IQ
When obtaining a health history, the nurse would assess the child's functional and developmental history. The nurse would assess what type of play the child prefers and where the child plays, types of toys, etc. to help determine functional ability. If a child plays only in the playpen the child is not exploring the world and is only playing with the toys placed in the playpen, not advancing creativity nor developmental skills. The child's IQ and developmental levels would require additional screening/testing that is not included in the health history.