Assessment of Children (EXAM 1)

A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? (Select all that apply) A. Death of a parent at a young age B. Recent or impending move C. Low parental expectations D. Volunteering at a community center after school E. Sudden decline in school performance

A, B, C, E

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply) A. Irritability B. Euphoria C. Insomnia D. Low self-esteem E. Chronic pain

A, C, D, E

A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. "All recent used clothing, bedding, and towels must be washed in hot water." B. "My child must be free from nits before returning to school." C. "I will treat all the family members to be on the safe side." D. "Toys that can't be dry cleaned or washed must be thrown out."

A. "All recent used clothing, bedding, and towels must be washed in hot water."

A nurse is providing teaching to the parents of a newborn. Which of the following information should the nurse include? A. "Your baby will receive a hepatitis B vaccine prior to discharge." B. "Your baby should receive the pneumococcal conjugate vaccine on his first birthday." C. "Your baby should receive the MMR vaccine at 6 months." D. "Your baby will receive the first diphtheria, tetanus, pertussis vaccine at the 2 week well-baby visit."

A. "Your baby will receive a hepatitis B vaccine prior to discharge."

A nurse is reviewing data for four children. Which of the following children should the nurse assess first? A. A 10-year-old child who has sickle cell anemia who reports severe chest pain B. A 7-year old child who has diabetes insipidus and a urine specific gravity of 1.016 C. A 1-year-old toddler who has roseola and a temperature of 39 degrees C (102.2 degrees F) D. A 4-year-old child who has asthma and a PCO2 of 37 mmHg

A. A 10-year-old child who has sickle cell anemia who reports severe chest pain Rationale: This is a medical emergency because it is a manifestation of acute chest syndrome therefore should be addressed first

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A. A child who has nephrotic syndrome B. A child recovering from a ruptured appendix C. A child who has rheumatic fever D. A child who has cystic fibrosis

A. A child you has nephrotic syndrome Rationale: A child who has leukemia is at risk for infection, nephrotic syndrome is not an infectious disorder poses no risk to a child who has leukemia A ruptured appendix, rheumatic fever, and cystic fibrosis all can be infectious

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane? A. At the end B. At the beginning C. Before examining the head and neck D. Before auscultating the chest and abdomen

A. At the end Rationale: Save invasive procedures for last, part of a modified head-to-toe approach

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect? A. Closed posterior fontanel B. Uses thumb and index fingers in a pincer grasp C. Lateral incisors D. Sitting steadily without support

A. Closed posterior fontanel Rationale: Posterior fontanel should close by about 8 weeks of age A 9-month-old should be able to use a pincer grasp, lateral incisors should develop between 9 and 13 months of age, an 8-month-old should be able to sit without support

A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? A. Irritability B. Slow, bounding pulse C. Decreased temperature D. Tetany

A. Irritability Rationale: An infant who is dehydrated will exhibit irritability, tachycardia, increased temperature Tetany is a manifestation of hypoglycemia

A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take? A. Wrap the arm of the child's doll or toy prior to the procedure B. Tell the child, "This will make your arm feel better" C. Place a heated fan at the bedside to facilitate drying D. Support the casted arm with a firm grasp

A. Wrap the arm of the child's doll or toy prior to the procedure Rationale: This action shows the child that it does not hurt the doll or stuffed animal, and, in turn, will not hurt the child Heat can cause burns, casts should be uncovered and allowed to dry from the inside out. A firm grasp may cause indentation, which can cause pressure areas

A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs? A. "Can I listen to your lungs?" B. "I am going to listen to your heart." C. "I am going to take your blood pressure now." D. "Can you stand very still while I feel how warm you are?"

B. "I am going to listen to your heart." Rationale: The nurse should inform the toddler of the procedure prior to taking vital signs The nurse should not ask yes/no questions, negativism is exhibited by toddlers as a way of asserting self-control, the nurse should avoid using the word "take"

A nurse is collecting data from an infant at a well-child visit. The nurse should understand that birth weight typically doubles by what age? A. 3 months B. 6 months C. 9 months D. 12 months

B. 6 months Rationale: Birth weight typically doubles by 6 months and triples by 12 months

A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires further intervention? A. Positive Babinski reflex B. Positive Moro reflex C. Negative Doll's eye reflex D. Negative Crawl reflex

B. Positive Moro reflex Rationale: The Moro reflex disappears at approximately 3-4 months of age Babinski reflex disappears after 1 year of age, a negative Doll's eye reflex is a normal findings, Crawl reflex disappears at about 6 weeks of age

A nurse is assessing a 10-month-old infant. Which of the following findings should the nurse report to the provider? A. The infant is unable to imitate animal sounds B. The infant does not sit steadily without support C. The infant cannot turn pages in a book D. The infant cannot build a tower of three or four cubes

B. The infant does not sit steadily without support Rationale: An 8-month old should be able to sit steadily without support. A 10-month-old infant should be able to change from a prone to sitting position, stand while holding onto furniture, and life one foot while standing A 12-month-old should be able to imitate animal sounds and turn pages in a book. A 18-month-old should be able to build a tower of three or four cubes

A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply) A. The preschooler stutters when speaking B. The preschooler mispronounces words C. The preschooler speaks in three word sentences D. The preschooler talks to himself when reading E. The preschooler speaks in a nasally tone

B. The preschooler mispronounces words D. The preschooler speaks in a nasally tone

A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider? A. The toddler cannot build a tower of six-to seven cubes B. The toddler cannot stand upright without support C. The toddler cannot jump with both feet D. The toddler cannot turn a doorknob

B. The toddler cannot stand upright without support

A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take? A. Use a 20-gauge needle B. Use a 1.8 mm (0.5 in) needle C. Insert the needle just below the acromion process D. Insert the needle at a 15 degree angle

B. Use a 1.8 mm (0.5 in) needle Rationale: the nurse should use the smallest size needle that will allow the medication to pass through the SQ tissue and enter the muscle The nurse should use a 22-25 gauge needle, 2 finger breadths below the acromion process, and insert the needle at a 90 degree angle

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address? A. "My parents treat me like a baby sometimes" B. "I haven't gotten my period yet, and all my friends have theirs" C. "None of the kids at this school like me, and I don't like them either" D. "There's a big pimple on my face, and I worry that everyone will notice it"

C. "None of the kids at this school like me, and I don't like them either" Rationale: This comment indicates the client might be at risk for depression, an eating disorder, or self-harm, therefore this comment is the priority for the nurse to address

A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately? A. A client who is 1 day postoperative and has a temperature of 37.5 C (99.5 F) B. A client who has a burn injury on an estimated 5% of his leg and is crying C. A client's blood pressure changes from 112/60 mmHg to 90/54 mmHg when standing D. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation

C. A client's blood pressure changes from 112/60 mmHg to 90/54 mmHg when standing Rationale: This is considered orthostatic hypotension, commonly caused by hypovolemia It is not unusual for a client to develop a slightly elevated temperature after surgery, crying is not a reason to call the provider immediately, increase in the level of pain with ambulation is expected

A nurse is an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take? A. Discuss self-defense techniques with the client B. Inform the client photographs of the injuries are required for a police report C. Ask the client to describe the situation D. Give the client a bed bath prior to physical examination

C. Ask the client to describe the situation Rationale: Encouraging the client to provide information which may be helpful with treatment and to reduce the client's anxiety

A nurse is caring for a 6-month0old infant. Which of the following findings indicate to the nurse that the infant may be experiencing pain? A. Dry palms and feet B. Decreased muscle tone C. Furrowed brow D. Eyes wide open

C. Furrowed brow Rationale: A furrowed brow may indicate that the infant is in pain or distress Pain indicators include diaphoresis, increased muscle tone, and shut eyes with open mouth

A nurse observes a parent administer a prescribed oral medication to an infant. Which of the following actions by the parent indicates a need for further instruction? A. Allows the infant to swallow some of the medication before administering more B. Administers medication with an oral syringe C. Positions the infant in a supine position D. Inserts the medication in the infant's buccal cavity

C. Positions the infant in a supine position Rationale: The parent should place the infant in a semi-upright position when administering medication to reduce the risk for aspiration

A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler? A. Explains the difference between right and wrong B. Prints letters and numbers C. Separates easily from primary caregiver for short periods of time D. Cooperates in doing simple chores

C. Separates easily from primary caregiver for short periods of time

A nurse is reviewing the history and physicality of an adolescent client who has conduct disorder. Which of the following is an expected finding? A. Death of client's father two months ago B. Experiences frequent facial tics C. Suspended from school several times in the past year D. Adheres strictly to routines

C. Suspended from school several times in the past year Rationale: Conduct disorder is an impulse-control disorder which includes a long-term pattern of violating the rights of other and performing violent or hostile acts

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute? A. "Newborns are abdominal breathers" B. "Newborns do not expand their lungs fully with each respiration" C. "Activity will increase the respiratory rate" D. "The rate and rhythm of breath are irregular in newborns"

D. "The rate and rhythm of breath are irregular in newborns" Rationale: Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate Other options are correct, however have no impact on obtaining a respiratory rate

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development? A. Tie colorful latex balloons to the side of the crib B. Provide a small electronic toy C. Change the infant's diaper as soon as soiling occurs D. Allow the infant to stand in the crib

D. Allow the infant to stand in the crib Rationale: Allowing the child to participate in normal developmental activities promotes growth and development. The infant can be held and allowed to walk in a cast or orthotic device

A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation? A. Uses a unidextrous grasp B. Has a fear of strangers C. Shows preferences towards foods D. Babbles one-syllable sounds

D. Babbles one-syllable sounds Rationale: A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds, therefore, this finding indicates a need for further evaluation

A nurse is assessing an adolescent client who has ADHD. Which of the following findings should the nurse expect? A. Emotional numbing B. Elevated mood C. Anxiety D. Impulsivity

D. Impulsivity

A nurse is assessing a preschooler who has a calcium level of 0.8 mg/dL. Which of the following findings should the nurse expect? A. Dry, sticky mucous membranes B. Polyuria C. Negative Chvostek's sign D. Muscle tremors

D. Muscle tremors Rationale: This is below the expected range

A nurse is preparing to administer the first measles, mumps, and rubella (MMR) immunization to a 15-month-old toddler. Which of the following findings is a contraindication for this immunization? A. The child has a cough and a temperature of 37.7 C (99.9 F) B. The child's temperature after the last set of immunizations was 38.3 C (101 F) C. The child is currently taking antibiotics for otitis media D. The child has a congenital immunodeficiency

D. The child has a congenital immunodeficiency Rationale: Congenital immunodeficiency is a contraindication to the MMR immunization A mild illness with a low grade temperature, an elevated temperature after previous immunizations, and antibiotics for a mild illness are not contraindications to MMR immunization