chapter 32 exam 3
The mother of a 9-month-old child reports her child's eyes are often crossed. The nurse confirms this during the examination. What action is indicated?
Report the findings to the physician. Persistent strabismus is normal in newborns. If noted after the age of 6 months it should be evaluated by a pediatric ophthalmologist. This will need to be reported to the physician so that the referral can be made.
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?
School age Screening for curvatures of the spine begin at school age when the child is most likely to develop this kind of deformity.
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 stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant.
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.
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." 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 nurse is measuring the head circumference of a 1-year-old infant during a well-child visit. The parent asks the nurse why this assessment is being performed. Which response will the nurse provide to the parent?
"Head circumference is typically assessed until age 2 or 3 to help determine if growth is appropriate.".
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 as 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.
The nurse is taking the health history of a 15-year-old client. What would be an appropriate way for the nurse to ask about the client's drug use history?
"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 teens 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 nurse is caring for a 10-year-old girl and is trying to obtain clues about the child's state of physical, emotional, and moral development. Which question is most likely to elicit the desired information?
"Tell me about your favorite activity at school?" A good health history includes open-ended questions that allow the child to narrate their experience. The other questions would most likely elicit a yes or no response.
The nurse brings a 2-day-old newborn into the mother's room in the postpartum unit. The mother voices concern that the newborn's hands and feet "look a little blue." Which response by the nurse is best?
"This is common for newborns up to several days of age. It happens because of the immature circulatory system trying to get used to being outside the uterus."
When performing an assessment for scoliosis the nurse asks the child to let both arms hang to the sides. Which observations would be an indication the child requires further screening? Select all that apply
-The elbows fall below the level of the iliac crest. -The elbows are not at the same level. -How straight the child is standing -The child leans toward one side.
The nurse is trying to establish a trusting relationship with an 8-year-old who was newly admitted for testing related to abdominal pain. Which actions by the nurse demonstrate effective actions in developing this relationship?
-The nurse sits down and talks to the child at eye level. -The nurse allows the child to decide whether she will auscultate the heart or lungs first. -The nurse asks the child about school, hobbies, friends, and interests. -The nurse encourages the child to tell the nurse how they feel and to point out areas that may be painful.
The nurse is assessing a 5-year-old's oral temperature. Which actions by the nurse indicate knowledge of the procedure?
-The nurse waits to measure the child's temperature 30 minutes after a nebulizer treatment -.The nurse encourages the child to keep the mouth closed during temperature measurement. -The nurse asks the mother if the child has had anything to drink recently.
Blood pressure monitoring becomes part of the routine health assessment at what age and older?
3 years Blood pressure monitoring becomes part of the routine health exam at age 3.
A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?
96.6°F (35.8°C)
The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation?
A bubble behind the tympanic membrane A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation. The other findings are within normal limits.
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 absence of normal speech and language development in a child.
A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam?
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.
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. Children 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.
When 12-year-old Chelsie comes in for her annual check-up, the nurse must take a health history and do a physical exam. What is the most appropriate manner for the nurse to obtain a health history?
Ask Chelsie if she minds if her mother is in the room with her.
The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?
Ask the parents to complete a day history. The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day. Day histories are fun to obtain because most parents are eager to describe a day with their child, and information gained this way is surprisingly rich and pertinent, much more so than if parents are just asked how their child sleeps, eats, or plays.
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 nurse is assessing the cardiac sounds of a child. Which action would the nurse incorporate into the assessment?
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.
Parents bring a toddler age 19 months to the clinic for a regular checkup. When palpating the toddler's fontanels (fontanelles), what should the nurse expect to find?
Closed anterior and posterior fontanels (fontanelles) By age 18 months, the anterior and posterior fontanels (fontanelles) should be closed. The diamond-shaped anterior fontanel (fontanelle) normally closes between ages 9 and 18 months. The triangular posterior fontanel (fontanelle) normally closes between ages 2 and 3 months.
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?
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
An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first?
Determine the type of ingestion. Utilizing the sense of smell during a health assessment helps the nurse to focus on finding a source for the odor and the potential cause of the odor. When the smell of camphor is present the nurse should evaluate for the ingestion of mothballs.
The nurse prepares to examine a 4-year-old boy. How would the nurse proceed?
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 The usual frequency of bowel sounds is 5 to 10 per minute.
The nurse is assessing a 4-year-old child who reports having ear pain. What would the nurse incorporate into the assessment?
Grasp the pinna and pull up and back gently in order to assess the ear.
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 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 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.
A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database?
Immunization record Immunization records are important to know in a health history of any child. If the child is missing any immunizations, the nurse can then educate the parents about vaccines and assist in scheduling immunizations.
The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse?
It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally." Light pink macule typically found on the eyelids, nasal bridge, or back of neck are called salmon nevi (or, more commonly, "stork bites"). They usually fade over time, but may never go away completely.
The nurse is examining an infant who is 4 days old. The nurse puts the infant in a semi-upright position and lets the head fall back (with immediate support). What infant reflex is the nurse testing?
Moro The Moro reflex is stimulated when the infant is semi-upright and the head falls backward. When this happens, the infant responds with symmetrical abduction and extension of the arms, flexion of the thumb, and flexion of the upper limbs. This response should not persist after 4 months of age. The Babinski sign is tested through stimulating the foot/toes. The palmar reflex is tested through the hand/fingers. The root reflex is tested through touch on the corner of the mouth.
The nurse is conducting a physical examination of a healthy 6-year-old. Which action should the nurse do first?
Observe the skin for its overall color and characteristics. The physical examination of children, just as for adults, always begins with a systematic inspection, followed by palpation or percussion, then by auscultation.
The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child?
The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The child who is able to sit can be weighed while sitting. Keep a hand within 1 in (2.5 cm) of the child at all times to be ready to protect the child from injury
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 will normally fade as the child ages. The lesions described are consistent with infantile (strawberry) hemangioma. They are benign and normally fade as the child ages, usually by the age of 9 years. Nevus flammeus (port-wine stain) are associated with the development of Sturge-Weber syndrome.
The parents of a 3-week-old infant question the presence of light pink "spots" on the back of their infant's neck. The nurse checks the areas and recognizes they are salmon nevi. What response by the nurse is most appropriate?
These will gradually fade but may not go away." The macules are often called stork bites. They are salmon nevi. They will fade but may never totally go away.
A 14-year-old male adolescent is brought to the clinic by his parent who is concerned the adolescent is developing an excessive amount of breast tissue. The examination confirms that the adolescent has slight enlargement of the breast tissue. What information should be relayed to the adolescent and his parent?
This is a normal and transient condition of adolescent males. Breast growth in adolescent males may occur in response to hormonal levels. This condition will self resolve as hormones become more balanced.
The nurse is assessing a 6-year-old child. The nurse instructs the child, "Let me see all of your pretty white teeth." Which cranial nerve is the nurse assessing?
VII The nurse is testing if cranial nerve VII was intact. The cranial nerve VII is the facial nerve and can be assessed by asking to see a child's teeth, having them smile, or lift an eyebrow. In infants facial symmetry would be assessed. Cranial nerve II is assessed by testing visual fields and visual acuity. Cranial nerve IV is tested by having the child move eyes downward and inward. Cranial nerve VI is assessed by checking for the ability of the eyes to move laterally.
The nurse is conducting a physical examination of a 10-year-old child. The nurse whispers the child's name from behind the child so that the child does not see the nurse's lips moving. Which cranial nerve is the nurse assessing?
VIII Testing a child's hearing by observing a response to a whisper without a visual clue assesses cranial nerve VIII, the acoustic nerve.
A nevus flammeus is
a dark purple-red flat patch and grows with the child. It is more commonly known as a port-wine stain.
An infantile (strawberry) hemangioma is
a raised reddish papule made of blood vessels. They recede over time, usually by age 9 years.
Cranial nerve IV is
assessed by having the child follow the light through the six cardinal positions of gaze.
Cranial nerve II
assesses the optic nerve.
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 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.
A 6-year-old child is brought to the facility by the parents who report that the child has had a fever for the past 2 days and now is reporting ear pain and pressure. The nurse conducts an otoscopic exam and suspects an inner ear infection based on which assessment finding?
bulging tympanic membrane If an ear infection is present, the tympanic membrane will appear reddened and will often bulge forward so the malleus is no longer discernible and the cone of light is absent. Wax (i.e., cerumen) in the ear canals appears as a dark-brown, glistening substance or flaky amber.
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?
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.
The registered nurse (RN) will intervene if the unlicensed assistive personnel (UAP) is noted performing which task?
pulling the earlobe down and back while checking a school-age client's tympanic temperature The RN would intervene if the UAP pulled the earlobe down and back as this is only done when the child is younger than 3 years of age.
The nurse is examining a child's skin for lesions and rashes. When documenting the findings, which would the nurse include?
color location size distribution When assessing the skin for lesions or rashes, the nurse would document the location, size, distribution of the lesions over the body, and distinguishing features of the primary or secondary lesion, including color, shape, raised, craterlike or flat, hard or soft if a mass, and exudate.
The nurse is examining a child and asks the child to show all of the teeth. For which cranial nerve would the nurse be testing?
cranial nerve VII The nurse would be testing to see if cranial nerve VII was intact. This is the facial nerve and can be tested by asking to see a child's teeth, or having the child smile or lift an eyebrow. In infants facial symmetry would be assessed.
The nurse is performing an assessment on a teen's clavicle strength. The teen is asked to shrug and raise the shoulders while the nurse applies gentle pressure to them. When documenting the findings, this should be identified as an assessment of which cranial nerve?
cranial nerve XI Test shoulder strength and the function of cranial nerve XI in the older child by requesting that the child shrug the shoulders while you apply downward pressure.
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?
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.
A nevus flammeus (port wine stain) is
dark purple-red. It is a flat patch that grows with the child.
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 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.
Purpura are
large purple macules created by bleeding under the skin.
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.
Petechiae are
pinpoint reddish macules that do not blanch when pressed.
For a child younger than 3 years,
pull the earlobe back and down. Insert the tympanic thermometer gently into the ear canal with the infrared sensor beam directed toward the center of the tympanic membrane rather than the sides of the ear canal.
Ecchymosis is
purplish discoloration that is more commonly known as a bruise.
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 Plethora is used to describe redness of the skin, especially the cheeks and lips.
Cranial nerve X is
responsible for speech and swallowing.
Cranial nerve IX is
responsible for swallowing and salivation.
Cranial nerve VII is
responsible for the tongue and facial movements.
The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark?
salmon nevus A light pink macule on the back of the neck is a salmon nevus or "stork bite."
A light pink macule on the back of the neck is
salmon nevus or "stork bite."
The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding?
swollen labia minora The newborn's labia minora is typically swollen from the effects of maternal estrogen. The minora will decrease in size and be hidden by the labia majora within the first weeks.
. Cranial nerve V is
tested to determine the muscles of mastication and sensation of light touch on the face
Cranial nerve V is
tested to determine the muscles of mastication and sensation of light touch on the face.
Cranial nerve II assesses
the optic nerve.
Plethora is
used to describe redness of the skin, especially the cheeks and lips