CAQ: Pediatric Assessment and Hospital Interventions

When does the anterior fontanel of an infant close? 1 At 4 to 10 months 2 At 8 to 12 months 3 At 12 to 18 months 4 At 18 to 26 months

3- At 12 to 18 months

A 7-year-old child is admitted for a diagnostic workup and is transferred from the emergency department to the pediatric unit. The nurse reviews the admission note and physical assessment. The nurse obtains the child's vital signs and talks with the parents. The parents ask the nurse why their child has severe headaches. What explanation should the nurse give for the cause of the headaches?

The child has an increased blood pressure, which can cause hypertensive encephalopathy, resulting in hyperperfusion of the brain and cerebral edema; one of the early signs of encephalopathy is a severe headache. Rapid respirations do not cause a severe headache. Anemia does not cause a severe headache. The autoimmune response associated with APSGN is not the cause of the severe headache.

The nurse instructs the unlicensed assistive personnel (UAP) to obtain vital signs from four clients. From which client can the nurse instruct the UAP to obtain a radial pulse? 1 A 1-year-old child 2 An 18-month-old child 3 A 30-month-old child 4 A 6-month-old child

3-A 30-month-old child A satisfactory pulse can be taken radially in children older than 2 years of age, hence, the nurse can instruct the UAP to obtain a radial pulse from a 30-month-old child. It is not generally possible to take a satisfactory pulse radially in children younger than 18 months, therefore the nurse should not instruct the UAP to obtain a radial pulse from these children.

During assessment, the nurse asks a client about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the client experienced pubertal delay. Which finding in the client's history supports the nurse's conclusion? 1 Weight increased by 8 to 12 kg. 2 Menarche occurred 2 years after thelarche. 3 Breast development occurred by 15 years of age. 4 Growth in height stopped 2 years after menarche

3-Breast development occurred by 15 years of age. When the development of breasts has not occurred by 13 years of age in girls, it is considered pubertal delay. An increase in weight between 7 and 25 kg is considered normal during the growth spurt period. The occurrence of menarche within 2 years of onset of breast development, or thelarche, is a normal finding. Generally in girls, growth in height stops 2 to 2.5 years after menarche.

A 1-week-old infant has been in the pediatric unit for 18 hours after placement of a spica cast. The nurse obtains a respiratory rate slower than 24 breaths/min; no other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later the infant experiences severe respiratory distress, and emergency care is necessary. What should be considered if legal action is taken? 1 Most infants' respirations are slow when they are uncomfortable. 2 The respirations of young infants are irregular, so a drop in rate is unimportant. 3 Vital signs that are outside the expected parameters are significant and should be documented. 4 The respiratory tracts of young infants are underdeveloped, and the respiratory rate is not significant.

Answer: 3 Vital signs that are outside the expected parameters are significant and should be documented. A respiratory rate of less than 30 breaths/min in a young infant is not within the expected range of 30 to 60 breaths/min; a drop to less than 30 breaths/min is a significant change and should be documented. Respirations will accelerate when there is discomfort. Any significant change should be reported immediately. The respiratory tract is fully developed at birth, and the respiratory rate is a cardinal sign of the infant's well-being.

According to Erikson's theory of psychosocial development, what is the correct order of a child's behavior as they age? 1. The child concentrates on work and play. 2. The child develops autonomy by making choices. 3. The child is concerned about appearance and body image. 4. The child develops feelings of superego or conscience.

The child is concerned about appearance and body image. The child develops autonomy by making choices. The child concentrates on work and play. The child is concerned about appearance and body image.

Children's patterns of play change as they grow from infancy through school age. Rank the order of appearance of each type of play, starting with infant play. 1. Associative 2. Cooperative 3. Parallel 4. Solitary

1- Solitary 2- Parallel 3- Associative 4- Cooperative The infant plays alone, with others initiating the play activity. Toddlers' play activity is described as parallel; they play beside other children but not with them. Preschoolers' play is associative in loose groups, with activities involving interaction among players. The school-age child is capable of cooperative play, which includes organized play such as sports, board games, and card games.

Which toddler behaviors should the nurse identify as ritualism during the health history portion of the assessment? Select all that apply. 1 Using the same cup with each meal 2 Being able to use a spoon efficiently 3 Eating the same foods as other family members 4 Refusing to eat if the different foods are touching 5 Rejecting a meal because it is served in a different bowl

1- Using the same cup with each meal 4- Refusing to eat if the different foods are touching 5- Rejecting a meal because it is served in a different bowl Toddlers are creatures of habit; behaviors that are indicative of ritualism include using the same cup with each meal, refusing to eat if the different foods are touching, and rejecting a meal because it is served in a different bowl. Being able to use a spoon efficiently is a fine motor skill. Eating the same foods as other family members is a developmental expectation as the child develops through the toddler stage to the preschool stage.

The nurse plans to perform an abdominal assessment of a 10-year-old child with suspected appendicitis. List in order of priority the techniques the nurse should use when assessing this child's abdomen. 1. Auscultating for bowel sounds 2. Asking where it hurts 3. Assessing the abdomen by touch 4. Visually examining the abdomen 5. Warming the stethoscope's diaphragm

1. Asking where it hurts 2..Visually examining the abdomen 3. .Warming the stethoscope's diaphragm 4..Auscultating for bowel sounds 5..Assessing the abdomen by touch

Which strategy needs to be employed while interviewing the adolescent as a part of her health-screening? 1 To start with more sensitive issues 2 To explain the limits of confidentiality 3 To ask more of close-ended questions 4 To interview the adolescent along with her parents

2- To explain the limits of confidentiality Explaining the limits of confidentiality helps to obtain reports on physical or sexual abuse. It also helps to get others involved if the client is suicidal. As per the nursing care guidelines, interview should include open-ended questions, when possible, in order to obtain detailed information about the client. As per the guidelines, interview should begin with less sensitive issues followed by more sensitive ones. In order to ensure privacy, it is preferable to interview the adolescent in the absence of parents.

The parents of a 2-year-old child are watching the nurse administer the Denver II Developmental Screening Test to their child. They ask, "Why did you make our child draw on paper? We don't let our child draw at home." What is the best response by the nurse? 1 "I should have asked you about drawing first." 2 "These drawings help us determine your child's intelligence." 3 "It lets us test the child's ability to perform tasks requiring the hands." 4 "I don't understand why drawing is forbidden in your home."

3- "It lets us test the child's ability to perform tasks requiring the hands." The Denver II Developmental Screening Test is one of the tests used to evaluate young children whose development appears to be behind the norm. It involves the use of a variety of methods to determine the level of development. The parents gave their consent to have the test done and were told that a variety of skills would be tested. A developmental screening test is designed not to test intelligence, but rather to test the child's ability to perform specific age-appropriate developmental tasks. It is inappropriate to question the parents' childrearing ability.

A child who recently returned from a three-day camping trip over spring vacation is brought to the clinic after a rash, chills, and low-grade fever develop. What are the most important data for the nurse to assess when taking the child's history? Select all that apply. 1 Date of return to school 2 Sports played on camping trip 3 Tendency to allergic reactions 4 Duration of signs and symptoms 5 Recent exposure to poison oak or ivy

3- Tendency to allergic reactions 4- Duration of signs and symptoms 5- Recent exposure to poison oak or ivy It is important to know whether the signs and symptoms are related to a history of allergies, a communicable infection contracted during the trip, or some other factor. The nurse must gather information regarding the duration of signs and symptoms because they could be related to a variety of factors that may or may not be linked to the camping trip. It is important to determine whether the child was exposed to a known allergen so appropriate treatment may be initiated. It is not necessary to know when the child is expected back in school; this information is unrelated to the situation. The child's problem is also unrelated to sports activities.

A nurse educates a mother about the proper administration of oral medication to her 4-year-old child. What statement made by the mother indicates effective learning? 1 "I should administer the medication with a cup or spoon." 2 "I should mix the medicine in a large amount of food." 3 "I should avoid giving a straw to my child to take pills." 4 "I should use a disposable oral syringe to prepare liquid doses."

4-"I should use a disposable oral syringe to prepare liquid doses." The mother should use a plastic, disposable oral syringe to prepare accurate liquid doses, especially those less than 10 mL. The mother should not give medicine through a cup, spoon, or dropper because of the risk of inaccurate measurements. The mother should refrain from mixing the medicine in a large amount of the child's food because the child may refuse to eat such a large quantity. The mother can use straws for her child to swallow pills.

The parents of a preschooler tell the nurse that they try to inculcate good eating habits by asking the child to be at the table until the "plate is clean." What condition is the child at risk for? 1 Anorexia 2 Depression 3 Aggression 4 Poor eating habits

4-Poor eating habits Asking the child to be at the table until the "plate is clean" results in overeating and develops poor eating habits later in life. Anorexia is seen if the child does not consume the required amount of food. Depression may be seen in a child if there are any psychological issues. Aggression occurs from sociocultural and familial influences on the child.

A nurse working the 7 am to 3 pm shift is caring for a 14-year-old adolescent for whom intake and output are being monitored. The primary healthcare provider prescribes an intravenous infusion to be administered at a rate of 50 mL/hr. The adolescent had 4 oz (120 mL) of milk and a muffin for breakfast at 8:30 am. At 9 am the adolescent vomited 200 mL. At 10 am the adolescent had 60 mL of water with medications. At 11 am the adolescent voided 550 mL of urine. For lunch, at 12:30 pm, the adolescent ate 3 oz (90 mL) of soup and 4 oz (120 mL) of ice cream. The adolescent voided 450 mL at 2 pm. Calculate the adolescent's total intake for the 7 am to 3 pm shift. Record your answer using a whole number. _____ mL

790 The client had 120 mL of milk (1 oz = 30 mL) at 8:30 am, 60 mL of water with medications at 10 am, 90 mL of soup at 12:30 pm, 120 mL of ice cream at 12:30 pm (counted as a liquid—it melts at room temperature), and 400 mL of IV fluid (50 mL × 8 hours = 400) for a total intake of 790 mL. Do not include the client's emesis or urine in the intake.

Which heart sound is normally heard in a toddler that is considered abnormal in an adult over 30-years-old? 1 S1 2 S2 3 S3 4 S4

An S3 is considered abnormal in adults over 30 years of age, but can often be heard normally in toddlers and young adults. S1, S2, and S4 are normally heard in older adults over 30 years of age and in children and athletes.

What in students is being assessed when a school nurse conducts audiometric screenings? 1 Hearing acuity 2 Sensorineural hearing loss 3 Auditory processing deficits 4 Hearing problems caused by wax

Answer: 1- Hearing acuity Audiometric screening permits assessment of hearing ability. It does not pinpoint the type of hearing loss. Processing deficits may occur without hearing deficits. Audiometric testing cannot identify hearing problems caused by an accumulation of earwax, although this type of hearing loss is possible.

Which questions should the nurse include when conducting a health history interview with the parents of a 4-year-old client to assess fine motor skills? Select all that apply. 1 "Is your child able to use scissors?" 2 "Is your child able to ride a tricycle?" 3 "Is your child able to tie shoe laces?" 4 "Is your child able to climb stairs using alternate feet?" 5 "Is your child able to build a tower using 9 or 10 blocks?"

1-"Is your child able to use scissors?" 3- "Is your child able to tie shoe laces?" Fine motor skills expected at 4 years of age include using scissors and being able to tie shoe laces; therefore, these questions are appropriate during the health history interview. Riding a tricycle is a gross motor behavior that is expected by 3 years of age. Climbing steps using alternate feet is a gross, not fine, motor skill that is expected by 4 years of age. Building a tower using 9 or 10 blocks is a fine motor skill expected by age 3, not age 4.

A nurse reviews with the parents of a young infant the principles of growth and development. Place the milestones in the order of their usual achievement. 1. Waves bye-bye and sits alone 2. Climbs stairs and drinks from a cup 3. Draws a vertical line and walks on tiptoe 4. Walks alone and builds a tower of two blocks 5. Sits momentarily without support and rolls over

1. .Sits momentarily without support and rolls over 2. .Waves bye-bye and sits alone 3. .Walks alone and builds a tower of two blocks 4. .Climbs stairs and drinks from a cup 5. .Draws a vertical line and walks on tiptoe The infant will sit momentarily alone without support and will roll completely over around 6 months of age. Waving bye-bye and sitting alone without support occur around 10 months of age. Walking alone and building a tower of two blocks take place by about 15 months of age. Climbing stairs and drinking from a cup are common around 18 months of age. Copying vertical and horizontal lines and walking on tiptoe occur around 30 months of age. Hand-eye coordination and balance have improved by this age.

What is the correct order of the steps in which the nurse should administer eardrops to a toddler?

1. Clean the outer ear using a washcloth. 2.Place the toddler in the side-lying position. 3..Pull the auricle down and back to straighten the ear canal. 4. .Hold the dropper 1 cm above the ear canal to instill the prescribed drops. 5. Keep the toddler in the side-lying position for 2 to 3 minutes. 6. Using a finger, apply gentle massage or pressure to the tragus.

A prescription for an isotonic enema is written for a 2-year-old child. What is the maximal amount of fluid the nurse should administer without a specific prescription from the healthcare provider? 1 100 to 150 mL 2 155 to 250 mL 3 255 to 360 mL 4 365 to 500 mL

3-255 to 360 mL Unless prescribed, no more than 360 mL of solution should be administered to a young child because fluid and electrolyte balance in infants and children is easily disturbed. Between 100 and 150 mL may be prescribed for a small infant. Between 155 and 250 mL may be prescribed for an older or larger infant. Between 365 and 500 mL is too much for a toddler.

During the assessment of a hospitalized infant, the nurse notes dry mucous membranes, absence of tears when the infant cries, and poor skin turgor. Which parameter will help the nurse further evaluate these findings? 1 Daily serum electrolytes 2 Respiratory rate and rhythm 3 Intake and output over the past 24 hours 4 Alterations in heart sounds since admission

3-Intake and output over the past 24 hours The infant is exhibiting signs of severe dehydration. The monitoring parameter that will be most helpful for evaluating these findings is intake and output, because checking this will help the nurse determine whether intake is adequate or fluid loss is excessive. Serum electrolytes, respiratory rate and rhythm changes, and certain changes in heart sounds are more likely to be the result of, rather than cause of, dehydration. Deteriorating cardiac function is more likely to lead to fluid retention than to fluid loss or dehydration.

A teacher's aide in a kindergarten class informs the school nurse that a male student said that his mother beat him and that he has bruises on the back and shoulders. What is the priority nursing action? 1 Notifying Child Protective Services 2 Reporting this information to the principal 3 Calling the parents to arrange a conference 4 Assessing the child for the presence of bruises

4-Assessing the child for the presence of bruises The nurse must validate the presence of physical injury and potential abuse before initiating other interventions. Child Protective Services, the school principal, and the parents should not be notified until signs of possible abuse are verified.

A toddler undergoes the implantation of a low-profile (skin-level) device (button) for a gastrostomy. The gastrostomy is now healed, and the parents are being taught to care for the stoma. What parental behavior indicates to the nurse that additional teaching is needed? 1 A parent is cleaning the stoma with soapy water. 2 Gastric contents are aspirated before the start of a feeding. 3 A parent inserts an adapter into the button to initiate a feeding. 4 The button is being maintained in the same position within the stoma.

4-The button is being maintained in the same position within the stoma. Further teaching is necessary because the button should be rotated to prevent adherence to the skin. The stoma and the skin around the button should be kept clean and free of drainage. As with other gastrostomy tube feedings, use of a gastrostomy button requires patency to be determined; residual gastric fluid should be present. Extension tubing should be inserted into the device for feedings.