Peds Ch 10

The nurse is meeting a 5 YO child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as

A way to establish rapport

A 5 YO girl is having a checkup before starting kindergarten. The nurse asks her to do the finger-to-nose test. The nurse is testing for:

Cerebellar function

Which tool measures body fat most accurately?

Calipers

When caring for a critically ill child, the nurse observes that respirations are gradually increasing in rate and depth, with periods of apnea. What pattern of respiration will the nurse document?

Cheyne-Stokes respirations

A 8 YO girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to:

Explain in simple terms how it works

A nurse is preparing to assess a 3 YO child. What communication technique should the nurse use for this child?

Focus communication on child

Which is the most appropriate vision acuity test for a child who is in preschool?

HOTV chart

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this?

Infection of inflammation close to the site

The nurse must assess a 10 MO infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and what might happen next. Which initial action by the nurse would be most appropriate?

Initiate a game of peek-a-boo

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?

Introduce self

The nurse has a 2 YO boy sit in tailor position during palpation for the testes. What is the rationale for this position?

It prevents cremasteric reflex

The nurse observes yellow staining in the sclera of eyes, soles of feet, and palms of hands. This should be interpreted as:

Jaundice

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize this diet:

May provide sufficient amino acids

A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?

Murmur

During examination of a toddler's extremities the nurse notes that the child is bowlegged. The nurse should recognize that this finding is:

Normal because the lower back and leg muscles are not yet well developed

During a funduscopic exam of a school age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is a(n):

Normal finding

Which is most important to document about immunizations in the child's health history?

Occurrence of any reaction after an immunization

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

Oral mucosa

The nurse must assess a child's capillary refill time. This can be accomplished by:

Palpating the skin to produce a slight blanching

The nurse is interviewing the mother of an infant. She reports "I had a difficult delivery and my baby was born prematurely. This information should be recorded under which of the following headings?

Past history

Where in the history should the nurse describe all details related to the chief complaint?

Present illness

During a routine health assessment, the nurse notes that an 8 MO infant has significant head lag. Which is the nurses most appropriate action?

Refer child for further evaluation

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?

Refer for immediate medical evaluation

A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern?

School-age child

The appropriate placement of a tongue blade for assessment of the mouth and throat is:

Side of the tongue

A nurse is preparing to test a school-age child's vision. Which eye chart should the nurse use?

Snellen letter chart

The nurse is using the NCHS growth chart for a Black child. Which statement should the nurse consider?

The NCHS charts are accurate for Black American children

The nurse's approach when introducing hospital equipment to a preschooler should be based on which principle?

The child may think the equipment is alive

What is the single most important factor to consider when communicating with children?

The child's developmental level

A nurse is assessing a patient admitted for an asthma exacerbation. Which breath sounds does the nurse expect to assess?

Wheezes

What is an important consideration for the nurse who is communicating with a very young child?

Use transition objects, such as a doll

Which communication technique should the nurse avoid when interviewing children and their families?

Using cliches

What type of breath sound is normally heard of the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium?

Vesicular

At what age should the nurse expect the anterior fontanel to close?

12-18 months

What is the earliest age at which a satisfactory radial pulse can be taken in children?

2 years

Parents of a newborn are concerned because the infants eyes often look crossed when the infant is looking at an object. The nurse responds that this is normal based on the knowledge that binocularity is normally present by what age?

3-4 months

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target?

3-4 months

The nurse has determined the rate of both the child's radial pulse and heart. When comparing the two rates, the nurse should expect that normally they:

Are the same

The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined?

Ask "why did you come here today?"

The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

Ask her "are you having sex with anyone"

The nurse is having difficulty communicating with a hospitalized 6 YO. What technique might be most helpful?

Ask the child to draw a picture.

Which approach would be best to use to ensure a positive response from a toddler?

Assume an eye-level position and talk quietly

A nurse is counseling parents of a child beginning to show signs of being overweight. The nurse accurately relates which BMI-for-age-percentile indicates a risk for being overweight?

85th percentile

Pulses can be graded according to a certain criteria. Which is a description of a normal pulse?

+3

At about what age does the Babinski sign disappear?

1 year

A nurse notes that a 10 MO infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?

1-2 years

Which would be the best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?

Axillary sensor

When interviewing the mother of a 3 YO child, the nurse asks about developmental milestones, such the age of walking without assistance. This should be considered:

An important part of the child's past history

The nurse is preparing to perform a physical assessment on a 10 YO girl. The nurse gives her the option of her mother either staying in the room or leaving. This action should be considered:

Appropriate because of the child's age

When the nurse interviews an adolescent, which is especially important?

Allow an opportunity to express feelings

The nurse is using calipers to measure skin-fold thickness over the triceps muscle in a school-age child. What is the purpose of doing this?

To measure body fat.

A nurse is performing an otoscopic exam on a school-age child. Which direction should the nurse pull the pinna for this age of child?

Up and back

Which of the following parameters correlate best with measurements of the body's total protein stores?

Upper arm circumference.

A nurse is preparing to perform a physical assessment on a toddler. Which approach should the nurse use for this child?

Use minimal physical contact initially

Which is most likely to encourage parents to talk about their feelings related to their child's illness?

Use open-ended questions