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When questioning a 15-year-old about his health history, what would be an appropriate way for the nurse to ask about the child's drug history?
"Have you heard that some teens like to smoke? Have you tried this?" When obtaining a health history from teens, the nurse should approach questions about sensitive subjects in a nonthreatening manner. This method may encourage the teen to not be afraid to ask questions and be more open. The other choices are all direct questions that may make the teen apprehensive or discourage him or her from being truthful when answering.
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?
Between the sternum and the left nipple 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 performing a physical exam on a 3-year-old boy. What method would the nurse use to perform the exam?
Examine the child's head and work down to the child's toes. A preschool or toddler child should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants, the examination starts with the chest, and then proceeds from head to toes.
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?
Five to 10 per minute The usual frequency of bowel sounds is 5 to 10 per minute.
During the physical examination, the nurse notes a positive Kernig and Brudzinski sign. The nurse interprets these findings to suggest which condition?
Meningeal irritation A positive Kernig and Brudzinski sign are indicative a meningeal irritation and are not associated with auditory or visual problems or heart murmurs.
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?
Place the tape measure around the head just above the eyebrows. 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.
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do?
Take the apical 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 nurse is interviewing the parents of a 3-year-old child brought to the emergency department for fever and fussiness. Which question is the best example to use when completing a health history about pain?
"Does your child have pain?" When conducting a health history the nurse should use therapeutic communication techniques such as active listening and eliminate any barriers to communication.Open-ended and close-ended questions can both be effective when used during a health history. Close-ended questions ask directly for a fact and are limited in scope. They require no further explanation. Asking "Does your child have pain?" is a closed-ended question and only requires a yes or no answer. The nurse can then explore the issue of pain with the parents. Asking about temperment does not address the issue of pain. Compound, expansive, and leading questions such as "Your child doesn't have pain does she?" should be avoided. Compound questions elicit information that is often inaccurate and require follow up questions. Asking "So, your child has been fussy?" is a statement and not a question. The parents could only respond yes or no and this would give the nurse no further information as to the child's symptoms.
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels, what should the nurse expect to find?
Closed anterior and posterior fontanels By age 18 months, the anterior and posterior fontanels should be closed. The diamond-shaped anterior fontanel normally closes between ages 9 and 18 months. The triangular posterior fontanel normally closes between ages 2 and 3 months.
The nurse is examining the heart and peripheral perfusion of an 8-year-old. The nurse will assess the apical impulse at which location?
The fifth intercostal space lateral to the left midclavicular line The apical pulse can be found at the fifth intercostal space lateral to the left midclavicular line in children over 7 years of age. The apical pulse's point of maximal intensity is at the fourth intercostal space just medial to the child's left midclavicular line until age 4 years and at the fourth intercostal space at the left midclavicular line from ages 4 to 6 years. The fifth intercostal space medial to the left midclavicular line incorrectly locates the apical pulse medially rather than laterally for someone over 7 years.
The mother of 2-year-old triplets is anxious and worried because one of the trio does not seem to be developing at the same rate as the other two. Which assessment finding would lead the nurse to question the need for further diagnostic testing for this child?
The tops of her ears are below the corners of her eyes The alignment of the ears is noted by drawing an imaginary line from the outside corner of the eye to the prominent part of the child's skull; the top of the ear, known as the pinna, should cross this line. Ears that are set low often indicate intellectual disability. Flaring of the nostrils might indicate respiratory distress and should be reported immediately. A child who speaks loudly, responds inappropriately, or does not speak clearly may have hearing difficulties that should be explored. It would be normal for the fontanelles to be closed by this age.
A nurse has just performed an assessment on a 12-year-old client and has identified a distended bladder that has a hyper-resonant (low, hollow) sound. Which technique did the nurse use to identify this sound?
percussion Percussion is an assessment technique performed by tapping body parts with the fingers, hands, or small instruments. It is used to determine the size, consistency and borders of organs and to mesaure the presence or absence of fluid. When a full bladder is percussed a dull sound is heard.The techniques of inspection is done by looking. Auscultation is performed by using the stethoscope and hearing. Palpation is done by feeling.
The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor related to taking a temperature?
"Rectal temperatures should not be taken on a child with diarrhea." A rectal temperature should not be taken in the newborn because of the danger of irritation to the rectal mucosa or in children who have had rectal surgery or who have diarrhea. A rectal temperature is usually 0.5° to 1.0° higher than the oral temperature and the axillary temperature is usually 0.5° to 1.0° lower than the oral temperature. It is easier to obtain a tympanic temperature in a sleeping child as the temperature can be obtained without walking them up.
The nurse is preparing to obtain anthropometric measurements on a child. The child's mother asks the nurse, "What are these measurements?" Which response by the nurse would be most appropriate?
"These are measurements that tell us how your child is growing." Anthropometric measurements include height, weight, and head circumference and can help determine the child's pattern of growth.
The nurse is obtaining health information from the parents of a 3-year-old. Which information is of most concern to the nurse?
"We are renovating an old farmhouse built in the early 1900s." Homes or apartments built prior to 1978 may contain lead-based paint, and children who live there are at an increased risk for the development of lead poisoning. This paint may be exposed during a renovation so there should be further discussion on this topic. Being a "stay-at-home mom," babysitting by grandparents in a new condo, and a well-cared-for pet are not concerns that need to be investigated further.
The nurse is conducting a health interview with the mother of a child coming to the clinic for an initial visit. Which question would be most appropriate for the nurse to ask the mother to elicit the chief complaint?
"What is the reason for your visit today?" The phrasing of questions used to conduct a health interview varies depending on the type of answer desired. Effective questions can be closed-ended or open-ended. Closed-ended questions directly ask for a fact. Open-ended questions ask for elaboration. Asking the reason for today's visit is open-ended and asks for specific information from the mother about the child's chief complaint. Asking "What is the problem?" labels the mother and asks her to define the illness, not why she is seeking care. Asking how long the child has been ill and about the child's history ask for the child's history and not the chief complaint.
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?
"What symptoms has your child exhibited?" 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.
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 delay or lack of clear, understandable speech pattern A hearing impairment will often cause a delay or absense 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 health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer?
1/4 to 1/2 inch (0.64 to 1.27 cm) The correct distance to insert a rectal thermometer is 1/4 to 1/2 inch (0.64 to 1.27 cm). One-eighth to
The nurse is measuring the head circumference of a newborn during a well-child visit. Until which age should the nurse take this measurement?
24 months Head circumference is measured at every visit until the child is 2 years of age.
Blood pressure monitoring becomes part of the routine health assessment at what age?
3 years Blood pressure monitoring become part of the routine health exam at age 3.
A 5-year-old child is being seen at the ambulatory care clinic for a well-child visit. The child is hiding behind his mother. What initial action by the nurse is indicated?
Allow the child to remain "hidden" during the initial part of the interview hildren may be shy when at the physician's office. To allow the child the opportunity to initially be "invisible" may be beneficial to help the child become acclimated to the surroundings. Telling the child to act like a big boy is not indicated and may "shame" the child and hinder the development of rapport between the nurse and the child. Eventually the child's mother may need to place him on the examination table but this should not be the initial action by the nurse. Promise of a small token may not work and should not be used at this time.
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 document the answers. 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.
A nurse is assessing a 3-year-old child. Which would be appropriate ways to approach the child during the exam? Select all that apply.
Ask the child if he/she would prefer to sit on the parent's lap for the exam. Give reassurance to the child during the exam. Preschoolers should have reassurance during the exam so they know things are going well. Having them sit on the caregiver's lap gives them a sense of security and can decrease stress. Clients of this age should be given short, simple explanations. It is inappropriate to tell a child to act "older." Children need to remove all clothing but their underwear for a full assessment
The nurse is obtaining the health history for a 9-year-old child who has been brought to the ambulatory care clinic with complaints of a backache. Which initial action by the nurse is most appropriate?
Ask the child when the pain started. When beginning the interview it is best to ask the child about the health complaints. If additional information is needed the parent should then be consulted. Palpating the back and asking the child to demonstrate movements takes place during the examination portion of the appointment and not the health history portion.
A 14-year-old female has been brought to the pediatric ambulatory care clinic for a "sports physical" by her mother. The teen tells the nurse she does not want to have her mother present during the examination. What action by the nurse is most appropriate?
Ask the teen's mother to wait in a separate area nearby until the physical examination has been completed. Teens may be modest and uncomfortable having a physical examination in front of their parents. When possible requests by teens for privacy should be granted.
The caregiver of an infant keeps removing the pulse oximetry sensor claiming it is too tight and hurting her baby. Which response should the nurse prioritize in addressing this situation?
Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin. Pulse oximetry measures the oxygen saturation of arterial hemoglobin. The probe of the oximetry unit can be placed on the finger, toe, or clipped on the earlobe. In an infant, the foot or toe is often used. In certain situations the probe is left in place to continually monitor the oxygen saturation. Check the site every 2 hours to ensure that the probe is secure and tissue perfusion is adequate. Change the site at least every 4 hours to prevent skin irritation. The probe cannot be taped to the chest wall and still collect the desired information. Respiratory retractions are determined by direct inspection of the chest wall.
The nurse is preparing to conduct the cover test with a preschool-age child. Which body system is the nurse preparing to assess?
Eyes A screening procedure to determine eye alignment is the cover test. The cover test is not used to assess the ears, nose, or neck.
The nurse is assessing the vital signs of several toddlers in the pediatric medical unit. Which findings are of most concern to the nurse?
Heart rate 60 beats per minute; respiratory rate 14 breaths per minute The normal heart rate for a toddler is 70-120 beats per minute and the respiratory rate is 20-30 respirations per minute. A heart rate 60 beats per minute and respiratory rate 14 breaths per minute are both below the normal range for toddler.
The nurse is taking a family history of a 10-year-old child with asthma. Which action would be the most helpful to gather information about the child's family health history?
Helping the family design a genogram A genogram is a visual description that shows the relationship between family illnesses and diseases over three generations, usually. Making a family tree, filling out a health questionnaire, or a family recording of their history puts the responsibility on the client and family and does not show any relationships among illnesses.
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?
Interviewing the child's caregiver 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.
A nurse is assessing an infant's reflexes. The nurse places his or her thumb to the ball of the infant's foot to elicit which reflex?
Plantar grasp Touching the thumb to the ball of the infant's foot would elicit the plantar grasp reflex. The other reflexes are not elicited by this method.
During an assessment, a child exhibits an audible high-pitched inspiratory noise, a tripod stance and intercostal retractions. Using SBAR communication, the nurse notifies the health care provider and states which breath sounds that are congruent with the clinical presentation of the child?
Respiratory stridor Stridor is a high-pitched, readily audible inspiration noise that indicates an upper airway obstruction. The child presents in severe respiratory compromise and struggles to breathe. A wheeze is a high-pitched sound heard on auscultation, usually on expiration. It is due to obstruction in the lower trachea or bronchioles. Rales are crackling sounds heard on auscultation when the alveoli become fluid filled. Rhonchi is a snoring sound heard throughout the lung field when inflammation occurs.
The nurse is caring for a 13-year-old girl. As part of a routine health assessment the nurse needs to address areas relating to sexuality and substance use. Which statement or question should the nurse say first to encourage communication?
Tell me about some of your current activities at school. The nurse should first begin with open-ended questions regarding work, hobbies, activities, and friendship in order to make the teen feel comfortable. Once a trusting rapport has been established, the nurse should move on to the more emotionally charged questions. While it is important to assure confidentiality, the nurse should first establish rapport.
Due to casts on both arms, the nurse must measure an 11-year-old client's blood pressure in the thigh. After placing the blood pressure cuff on the thigh, which action by the nurse demonstrates understanding of the procedure?
The nurse places the stethoscope over the popliteal artery The stethoscope should be placed on the artery nearest, but below the blood pressure cuff.
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?
The reflex is diminished. 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.
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?
Vomiting 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.
