PEDSTest/quiz 2: Chapter 28

The nurse is beginning a health history with a 3-year-old child. Which question would the nurse ask the mother first? "Is your child ill in any way?" "Tell me about your child." "Has your child been ill in the past?" "Do you have any concerns about your child?"

Correct response: "Do you have any concerns about your child?" Explanation: The most appropriate question to begin a health history is open-ended. This type of question allows the parent to elaborate on the health of the child. Close-ended questions such as asking if the child has been ill or if the child has been ill in the past limit the amount of information learned for the history. Expansive statements such as "tell me about your child" are too vague.

The nurse is caring for an infant involved in a motor vehicle accident. The nurse uses the modified coma scale for infants and notes the following: spontaneous eye opening, moaning to pain, and withdraws to pain. Which score will the nurse record? 10 9 8 7

Correct response: 10 Explanation: The modified coma scale for infants may be used for infants instead of the Glasgow coma scale. The scale is broken down into eye opening, verbal response, and motor response. The infant's score is 10 based on these categories. The remaining answer choices are incorrect.

The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child's heart rate will be in what range? 80 to 150 bpm 70 to 120 bpm 65 to 110 bpm 60 to 100 bpm

Correct response: 60 to 100 bpm Explanation: The normal heart rate for a school-age child is 60 to 100 bpm, for an infant is 90 to 160 bpm, for a toddler or preschooler is 80 to 115 bpm.

On what client would it be appropriate for the nurse to perform a rectal temperature? A newborn infant during the initial assessment A toddler who is admitted with rotavirus and frequent diarrhea A child who has suffered a head injury and is comatose A post-cardiac surgery patient

Correct response: A child who has suffered a head injury and is comatose Explanation: Rectal temperatures are not the preferred method of obtaining a child's temperature but are appropriate if the child is unconscious and the nurse cannot do an oral temperature. Clients who have diarrhea, hemorrhoids or are cardiac patients are not appropriate candidates for rectal temperatures. The rectal thermometer can cause arrhythmias in cardiac patients, irritate the rectal mucosa further in patients with diarrhea and in newborns.

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? Thoracic muscle Accessory muscle Intercostal muscle Abdominal muscle

Correct response: Abdominal muscle Explanation: 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 nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which of the following sites to obtain an accurate assessment? Radial pulse Brachial pulse Apical pulse at the third or fourth intercostal space Apical pulse at the fourth or fifth intercostal space at the midclavicular line

Correct response: Apical pulse at the third or fourth intercostal space Explanation: For children younger than 2 years of age, the nurse should auscultate the apical pulse with the stethoscope at the point of maximum intensity just above and outside of the left nipple at the third or fourth intercostal space. The radial pulse is difficult to palpate accurately on children younger than 2 years of age because the blood vessels lie so close to the skin surface and are easily obliterated. The brachial pulse is not the best point of auscultation. The point of maximum intensity (PMI) is heard best at the fourth or fifth intercostal space at the midclavicular line beginning around 7 years of age.

Question 3 of 20 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 write the answers down. Have the child read the questions to the caregiver and then write down the answers on the form. Ask the caregiver if he or she can read or if they need someone to read the questions on the admission form to them. Have the caregiver sit in a quiet room and fill out a questionnaire.

Correct response: Ask the caregiver questions and write the answers down. Explanation: The family caregiver provides most of the information needed in caring for the child, especially the infant or toddler. Rather than simply asking the caregiver to fill out a form, it may be helpful to ask the questions and write down the answers. This provides a personal interaction between the nurse and the caregiver. If the caregiver can not read then the nurse would help with the completion of the form by asking questions and documenting the answers. Children should not be used as interpreters or complete a form. If the child is under the age of 18 it would not be a legal document and with a child's language skills and comprehension much needed information could be not obtained.

The nurse preceptor observes a novice nurse perform a pediatric assessment. Which action by the novice nurse will the nurse preceptor determine is a normal variance to assessment technique when compared to the assessment of an adult patient? Skipping the review of systems portion of the assessment Assessing the abdomen before assessing the head and neck Deferring the focused exam portion of the assessment Assessing the mental status before assessing the lungs

Correct response: Assessing the abdomen before assessing the head and neck Explanation: The only difference with a pediatric assessment versus an adult assessment is that the pediatric assessment may not always be performed in a head-to-toe fashion. Assessing the abdomen before assessing the head and neck may be completely appropriate, depending on the patient's condition. This would not require follow-up by the preceptor. Pediatric assessment includes a review of systems and focused exam and is performed on every patient. Assessing the mental status before the lungs follow the head-to-toe fashion and is not considered a normal deviance to the assessment.

When the nurse performs her head-to-toe assessment on a 2-year-old child, when would she examine the child's ears? When examining the head and face At the start to get it over with At the end of the exam in case the child gets upset After she is finished examining the entire head and face

Correct response: At the end of the exam in case the child gets upset Explanation: The nurse should do any type of intrusive examination, such as of the mouth or ears, at the end of the physical exam so as not to distress the child. The other choices all could cause distress to the child before or during the exam.

Question 8 of 20 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 abdominal movements. Count after the child stops crying and is comfortable. Place a stethoscope to count respirations. Count the respiratory rate for 30 seconds.

Correct response: Count after the child stops crying and is comfortable. Explanation: Respirations should be assessed when the child is resting or sitting quietly because respiratory rate changes significantly when children cry, eat, or become more active. They also breathe more rapidly when anxious or frightened. Counting respirations for a full minute assures accuracy. Infants' respirations are primarily diaphragmatic; therefore, counting abdominal movements promotes accuracy. Placing a stethoscope to count respirations tends to be seen as invasive by a toddler and will result in movement away or an increase in respirations.

The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In order to get an accurate reading, what does the nurse need to do? Pull the earlobe back and down Direct the infrared sensor at the tympanic membrane Pull the earlobe down and forward Remove any visible cerumen from inside the ear canal

Correct response: Direct the infrared sensor at the tympanic membrane Explanation: The accuracy of tympanic temperature reading is dependent upon appropriate technique. The nurse needs to be sure to direct the infrared sensor at the tympanic membrane. Since the child is older than age 3, the earlobe does not need to be pulled back and down. The nurse would not remove earwax from inside the ear canal.

When percussing the chest of an infant the nurse hears hyperresonant sounds. What action should the nurse take? Notify the health care provider. Document the finding. Obtain and order for a chest x-ray. Obtain an order for a breathing treatment.

Correct response: Document the finding. Explanation: Percussion of the lung sounds reveal resonance in older children. The sound will be hyperresonant in infants and younger children due to the thinness of the chest wall. Overexpanded lungs will sound hyperresonant in older children. Lungs filled with fluid sound dull in older children and less resonant in younger children. Because these are normal findings in an infant documentation is the only necessary step the nurse should take.

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? Have you kept the child up to date on all of the immunizations suggested? Do you have the immunization book for us to review? When did the child have his/her last immunization? Were there any side effects from the last immunizations?

Correct response: Have you kept the child up to date on all of the immunizations suggested? Explanation: A leading question supplies its own answer. This questions 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. Reference:

When assisting with the physical exam of a 1-year-old child, the nurse notes the following findings. Which finding would be concerning to the nurse? Clear drainage coming from the nose Ears are aligned with the top of the eyes Heart rate of 80 Breaths are counted by observing the rise and fall of the abdomen

Correct response: Heart rate of 80 Explanation: The normal heart rate for a 1-year-old infant is 90 to 170 beats per minute, with an average rate of 120 to 130; a heart rate of 80, therefore, is concerning and needs to be reported to the physician. Clear drainage is a common finding in young children and is not concerning. Ear alignment is normal. Health care providers are only concerned when the ears lie below the level of the eye. Abdominal respirations are quite normal for infants.

The nurse is preparing to assess a school-age child who is experiencing pain in the left femur area. When conducting this assessment, at which point should the nurse assess the painful region? Last First After measuring vital signs Before the abdominal assessment

Correct response: Last Explanation: If a child has a sensitive or painful body part, palpate that area last. Otherwise, the child may be unwilling to allow other parts to be touched in fear of additional pain. The painful regions should not be assessed first, after measuring vital signs, or before the abdominal assessment.

The nurse assesses the heart of a 13-year-old and notes the presence of a fourth heart sound. What would the nurse do next? Obtain an apical pulse rate Notify the health care provider Document the finding Assess for pulse deficit

Correct response: Notify the health care provider Explanation: The presence of a fourth heart sound generally signifies heart pathology. This sound is called a gallop rhythm and is caused by an abnormal filling of the ventricles. This causes increased pressure on the valves. Physiologic splitting is the term when the pulmonary valve closes slightly later than the aortic valve. Murmurs cause the heart to pump with abnormal force. If the heart is struggling a thrill can be felt on the chest wall. The health care provider should be notified of this finding. Pulse measurements help the health care provider in making a diagnosis but the health care provider should be notified first.

The nurse is performing an examination of the eyes of a 7-year-old girl. Which finding would indicate that the third cranial nerve is intact? Pupil constriction in response to light Pupil dilation in response to light The eyelid blinks in response to touching the cornea with a wisp of cotton Light of an otoscope reflecting evenly off both pupils

Correct response: Pupil constriction in response to light Explanation: If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment.

The nurse is preparing to assess the pulse of an 18-month-old child. Which pulse would be most difficult for the nurse to palpate? Radial Brachial Pedal Femoral

Correct response: Radial Explanation: In a child younger than 2 years of age, the radial pulse is very difficult to palpate, whereas the pedal, brachial, and femoral pulses are usually easily palpated.

The nurse begins the physical exam to obtain the child's vital signs. Which would the nurse assess first? Respirations Pulse Temperature Blood pressure

Correct response: Respirations Explanation: The child's respirations are measured first before any other measurements that may affect the rate.

A nurse is conducting the health history of a 5-year-old child. Which data would the nurse collect last? Review of systems Current medications Allergy history Spiritual history

Correct response: Review of systems Explanation: The last component of a comprehensive pediatric health history is the review of systems. Current medications and allergy history are gathered when obtaining information about the child's past medical history. The child's spiritual history is obtained after reviewing the family health history.

The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? Heart Abdomen Lungs Throat

Correct response: Throat Explanation: If the infant is asleep, the nurse should auscultate the heart, lungs, and abdomen first while the baby is quiet. The nurse performs the assessment in a head-to-toe manner, leaving the most traumatic procedures, such as examination of the ears, nose, mouth, and throat, until last.

All infants should have their head circumference measured at health-assessment visits. Where should the nurse place the tape measure to obtain this measurement? just above the eyebrows through the prominent part of the occiput the center of the forehead to the base of the occiput the hairline in front to the hairline in back the middle of the forehead through the parietal prominences

Correct response: just above the eyebrows through the prominent part of the occiput Explanation: To measure the circumference of an infant's head, the nurse would measure the largest point across the skull, not including the ears, with a nonstretching cloth or paper tape. The tape would be placed at the forehead just above the eyebrows and brought around the head in a taut circle just above the occiput prominence at the back of the head. The measurement is then marked on a growth chart so it can be plotted to assess adequate growth. Each of the other options depict incorrect placement of the tape for measurement and would not provide a correct measurement of the head.