ch32: health assessment
The nurse is obtaining a functional history during an admission assessment of a 12-year-old child. Which questions would be appropriate for the nurse to ask during this part of the assessment? Select all that apply. "Do you wear a seat belt any time you are a passenger in a car?" "Are your parents married?" "Do you use a computer or a smartphone?" "Do you know if your family has a history of any heart problems?" "Can you tell me if you play any sports or participate in any physical activities?"
"Do you wear a seat belt any time you are a passenger in a car?" "Do you use a computer or a smartphone?" "Can you tell me if you play any sports or participate in any physical activities?" The functional history should contain information about the child's daily routine. Questions such as the amount of physical activity, car safety, and use of computers and smartphones (including the amount of time on these devices) are included in this assessment. Asking about heart problems is included in the family history assessment, and asking about parents is included in the family composition assessment.
The parents of an 8 year-old state, "I am happy that our child is healthy," when the nurse says that the child falls into the 95th percentile for BMI. How should the nurse respond? "For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level." "I will let the physician know that your child is in the 95th percentile for BMI." "The 95th percentile is not an indication of health." "Being in the 95th percentile for BMI is not a good thing. Your child is on the verge of obesity. It would be a good idea to consider this with meal planning."
"For a child a BMI between the 85th and 95th percentile alerts us to the risk for being overweight. Let's talk about your child's diet and activity level." BMI between the 85th and 95th percentiles for children between the ages of 2 and 20 indicates risk for overweight. BMI greater than the 95th percentile indicates the child is overweight. Informing of the parents of these findings and discussing diet and activity effectively address the issue in a therapeutic way.
The nursing students are learning how to perform a health assessment on a pediatric client. The nursing instructor identifies a need for further teaching when a student states: "I should take blood pressure on a child beginning at age 3 years." "I should establish good rapport with the child's parents before beginning an assessment on a child." "I should take a temperature using an electronic thermometer beginning at age 3 years." "I should take blood pressure on a child beginning at age 2 years."
"I should take blood pressure on a child beginning at age 2 years." When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The recommendations are that blood pressure assessment be done at least once during every health care visit on children aged 3 years and older. Children younger than 3 years should have blood pressure assessed if they have a history of prematurity, have congenital heart defect, have a urinary tract infection, take any medications that influence the blood pressure or have increase intracranial pressure. Blood pressure measurement on hospitalized children is taken according to hospital policy no matter what age. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years.
Blood pressure monitoring becomes part of the routine health assessment at what age and older? 4 years birth 1 year 3 years 2 years
3 years Blood pressure monitoring becomes part of the routine health exam at age 3.
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
Abdominal muscle 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.
A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam? Explain the procedure to the child. Allow the child to play with the tuning fork. Demonstrate the procedure on the mother. Explain that no pain is involved.
Allow the child to play with the tuning fork. To conduct the Weber test for hearing function the nurse would strike a 500-Hz tuning fork and hold the stem of it against the top of the child's head. The child with normal hearing in both ears will hear the sound equally well with both ears. If the child has an air conduction loss in one ear, the child will hear the sound better in that ear rather than the good ear. The test is used in conjunction with other evaluation tools because if the sound is intensified in one ear, it may mean that there is no hearing perception (i.e., there is nerve loss) in the opposite ear. Explaining and demonstrating the procedure to the child may be important, but developmentally the child needs to be able to see, feel, and hear all equipment being used.
The nurse is performing an assessment of the genitalia of a 15-year-old male. The nurse notes that the pigment of the skin of the scrotum is much lighter than the rest of the client's skin color. What is the nurse's best action? Talk with the client's parents to see if they were aware of this pigment issue. Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin. There is no need to address this issue since this is a normal finding for an adolescent male. Document the findings so there is proof of the assessment findings.
Ask the client if the scrotal skin has always been lighter in pigment than the rest of the patient's skin. While assessment findings do need to be documented, the nurse should ask the client if this finding has always been present because the scrotum is normally darker in color than the rest of the body's skin. The client is old enough to ask him rather than initially speaking with the parents.
The nurse is assessing the cardiac sounds of a child. Which action would the nurse incorporate into the assessment? Auscultate the cardiac sounds over the three prominent valvular areas on the chest. Auscultate the apical heart rate for 30 seconds and multiply by 2 to obtain the beats/minute. Auscultate the heart sounds with the child in both the upright and the prone positions. Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds.
Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds. The nurse would auscultate the child's heart sounds in the area of the PMI. The nurse would listen for a full minute, not 30 seconds x 2, which is not as accurate. The nurse would assess the child's heart sounds in the upright position and in the reclined position. The nurse would assess over four valvular areas of the heart, not three.
The nurse is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client? Observation of walking gait Standing height measurement Blood pressure recording Snellen vision testing
Blood pressure recording
The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take? Applaud the good technique. Counsel the new graduate. Demonstrate the appropriate technique. Explain why the technique is incorrect.
Demonstrate the appropriate technique. A cremasteric reflex is elicited by stroking the medial aspect of the thigh in boys. With this, the testes move perceptibly upward. The presence of this reflex indicates integrity of the first and second lumbar nerves. Abdominal reflexes should be assessed in both sexes. An abdominal reflex is elicited by lightly stroking each quadrant of the abdomen. Normally, the umbilicus moves perceptibly toward the stroke. Presence of this reflex indicates integrity of the 10th thoracic nerve and the first lumbar nerve of the spinal cord. The new graduate nurse needs to be shown the correct aspect of the thigh to stroke so that she/he can perform the technique correctly in the future. Explaining why the technique is incorrect does not show the nurse how to perform the procedure correctly. The charge nurse would not want to applaud an incorrect procedure, nor is this reason to counsel the nurse.
When assessing heart sounds on a high school athlete, the nurse hears a "lub d-dub" sound which is associated with inspiration. What action will the nurse take? Refer the student for a stress test. Document the findings as normal. Refer the student for an electrocardiogram. Notify the health care provider.
Document the findings as normal. With inspiration and the resulting increase or pressure in the lungs, the pulmonary valves close slightly later than the aortic valve. This causes a variation in heart sounds. This is termed physiologic splitting and is heard as a "lub d-dub" sound. As long as this sound is associated with inspiration, it is a normal finding. If splitting were to be consistently heard, it would indicate difficulty with the pulmonary valve closing and suggest pathology. Because this is a normal finding no referrals need to be made.
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 extremities first and then the chest. Examine different sections of the body at various times. Examine the child's head and work down to the child's toes. Examine the child's chest and then go to the head and down.
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.
The nurse prepares to examine a 4-year-old boy. How would the nurse proceed? Examine the child's chest and then go to the head and down. Examine the child's extremities first and then the chest. Examine the child's head and work down to the child's toes. Examine different sections of the body at various times.
Examine the child's head and work down to the child's toes. Preschoolers or young children should be examined starting from their head and working down all the way to their toes for a thorough exam. In infants and young children, 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 Thirty to 40 per minute Sixty per minute One to two per minute
Five to 10 per minute The usual frequency of bowel sounds is 5 to 10 per minute.
A nurse is testing a client for strabismus and amblyopia using the cover-uncover test. Which is the likely developmental age of the client? Preschool-age child School-age child Child younger than age 2 years Child younger than age 18 years
Preschool-age child The cover-uncover test is reliable for assessing strabismus in children older than 2 years. One can test the corneal light reflex in children older from age 6 months to 24 months, but it is not reliable. If testing is not done until school age, a vision loss may have occurred.
A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate? Preschool age Young adulthood Adolescence Infancy School age
School age Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.00
The nurse is performing an admission assessment on a 12-year-old who suffered a head injury in a motor vehicle accident. Which finding will alert the nurse that the client is demonstrating complications from the accident? The child is able to rate his pain at a 5 on a scale of 0 to 10 when describing his headache. The nurse notes waxy cerumen that is soft and an orangish-brown color when assessing the ear canal. The child's pulse rate is 90 beats per minute and the respiratory rate is 22 breaths per minute. The nurse brings an ink pen toward and away from each eye and notes the pupil dilating as the object moves closer.
The nurse brings an ink pen toward and away from each eye and notes the pupil dilating as the object moves closer. The eyes demonstrate accommodation, or focusing at different distances, if the pupil constricts as the object moves closer; dilating would indicate a possible neurologic issue. Normal vital signs for a school-age child include a pulse of 60 to 100 bpm and a respiratory rate of 14 to 22 breaths per minute. Being able to rate pain shows intact neurologic status. Cerumen lubricates and protects the external ear canal and is normally orangish-brown in color.
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply. The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. The nurse takes the child's vital signs and height and weight. The nurse observes the general appearance of the child.
The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting. Most subjective data are collected through interviewing the family caregiver and the child. Subjective is the data collected from another source or data that the nurse can not assess, such as pain. No one can feel the pain the client is experiencing. Objective data is information which can be gathered by direct assessment. Getting the necessary information from the caregiver would be a form of subjective data. Taking the vital signs and visual inspection are forms of objective data.
The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct? These lesions are associated with the development of Sturge-Weber syndrome. Biopsies of these areas are usually taken once the child is a teen. Once the child has grown these lesions are usually removed by lasers. These lesions will normally fade as the child ages.
These lesions will normally fade as the child ages. The nurse is completing an assessment on a 2-year-old child. The nurse notes the presence of a raised reddish purple spot on the back of the child's neck. Which statement about this finding is correct?
While at school, the client is called to the school nurse's office. The school nurse is performing secondary prevention interventions. Which would the nurse most likely be performing? assessing vision checking temperature asking the client if he or she likes school asking the client about what he or she usually eats each day
assessing vision Hearing and vision screenings are examples of secondary prevention in health assessments. These are usually state-or federally-mandated screenings to prevent risk factors of specific diseases.
The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment? back and extremities; head and neck; then the ears, nose, mouth, and eyes head and neck; eyes, ears, nose, mouth; then the back and extremities back and extremities; eyes, ears, nose, mouth; then the head and neck eyes, ears, nose, mouth; back and extremities; then the head and neck
back and extremities; head and neck; then the ears, nose, mouth, and eyes Data are collected by examination of the body systems. Often the exam for an infant is not done in a head-to-toe manner, as is done with adults, but rather in an order that takes the infant's age and developmental needs into consideration. Because the infant is asleep and held against the parent's shoulder, the nurse would begin by assessing the infant's back and extremities. The infant's eyes would be inspected last to allow the infant to be most comfortable until the end of the assessment. Aspects of the examination that might be more traumatic or uncomfortable for the infant are completed last.
A nursing instructor is teaching students how to assess a newborn and emphasizes the importance of taking femoral pulses. Doing so will help to rule out which condition? hypotension peripheral disease coarctation of the aorta pulmonary hypertension
coarctation of the aorta When performing an assessment on a newborn, it is important to assess the femoral pulse to rule out coarctation of the aorta. The narrowing, or coarctation, of the aorta causes blood to flow to the upper part of the body but not the lower part. The upper half of the body is warm and perfused while the lower is cool and pale. This diagnosis can also be ascertained by B/P readings. If the reading is lower in the leg than the arm then coarctation should be considered. Hypotension would be determined by B/P measurement, not palpating a pulse. Peripheral disease can be arterial or venous in nature. These would be assessed either from the popliteal or dorsal pulses. Pulmonary hypertension is high B/P in the arteries of the lungs. It could not be determined by palpating a peripheral pulse.
A 6-month-old has fanning of the toes and dorsiflexion of the big toe seen on physical exam. Based on this finding the nurse should: teach parent to have child wear hard-soled shoes. refer for further evaluation. educate the parent about the abnormal finding. document as a normal finding.
document as a normal finding. The infant should be assessed for a Babinski reflex. To achieve this stroke the sole of the foot. Fanning of the toes will occur in infants younger than 3 months of age. A downward reflex of the toes will occur beyond 3 months of age. Some infants will demonstrate a flaring Babinski sign until 2 years of age. In the absence of other neurologic findings this is a normal response. The nurse would document this normal finding. The child would not need to be referred for further evaluation. The finding does not indicate any particular type shoe the child would require.
A nurse is preparing to examine the ear of a 2-year-old child. The nurse would pull the pinna in which direction? down and back up forward up and back
down and back The nurse should pull the pinna of the ear down and back for a child younger than age 3 years to help straighten the ear canal. For a child older than age 3 years, the pinna is pulled up and back.
All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? the middle of the forehead through the parietal prominences the center of the forehead to the base of the occiput just above the eyebrows through the prominent part of the occiput the hairline in front to the hairline in back
just above the eyebrows through the prominent part of the occiput 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 no stretching 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 depicts incorrect placement of the tape for measurement and would not provide a correct measurement of the head.
The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact? eyelid blinks in response to touching the cornea with a wisp of cotton pupil constriction in response to light pupil dilation in response to light light of an otoscope reflecting evenly off both pupils
pupil constriction in response to light 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.
A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe? redness of the cheeks and lips round flat lesions on the neck bluish coloration of lips and nail beds black and blue areas on the skin
redness of the cheeks and lips. Plethora is used to describe redness of the skin, especially the cheeks and lips. Cyanosis refers to the bluish discoloration of the skin and mucous membranes. Macules are round flat lesions. Ecchymoses are large, diffuse areas of black and blue color.
Where is the point of maximal impulse (PMI) found in a 5-year-old child? the sternum the third intercostal space the fourth intercostal space the clavicle
the fourth intercostal space The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. Up until the age 4 years it is located between the 3rd and 4th intercostal space (ICS). From ages 4 to 6 years it is found at the 4th ICS medial to the left midclavicular line. From age 7 upward it is located at the 5th ICS lateral to the left midclavicular line. Heart sounds radiate and can be heard either to the right or left of the sternum but never directly over the sternum. The clavicle is located too high to hear heart sounds.
The nurse is preparing to perform a physical examination of a toddler. Which is the preferred location to complete the assessment? with the child sitting on the examination table with the caregiver outside the examination room with the child sitting on the examination table making eye contact with the caregiver with the child seated on the caregiver's lap with the child lying on the examination table with the caregiver right beside the child
with the child seated on the caregiver's lap Allow some freedom of movement when possible; the child may stand between the seated caregiver's legs or sit on the lap of the caregiver. Lying on the examination table with the caregiver right beside the child would be the preferred location for an infant. Sitting on the examination table with eye contact would be the best location for a school-aged child. Sitting on the examination table with the caregiver outside the room would be appropriate with adolescents.
