ch 32 assessment of a child Flashcards
the nurse is conducting a health history for a 9 year old child with stomach pains. what is a recommended guideline when approaching the child for information?
allow the child to control the pace and order of the health history
for which children would the nurse conduct an immediate comprehensive health history?
a child who is a new client in a pediatric office
the nurse is performing a health history on a 6 year old boy who is having trouble adjusting to school. which question would be most likely to elicit valuable information?
what are your new classmates like?
the nurse performing a health history on a child asks the parents if their child has experienced increases appetite or thirst. what body system is the nurse assessing with this question?
endocrine
the nurse is questioning the parents of a 2 year old child to obtain a functional history. which topics might the nurse include? select all that apply
-the child’s toileting habits
-use of car seats and other safety measures
-use of supplements and vitamins
the nurse is conducting a physical examination of a child following a comprehensive health history. what should the focus of the physical examination?
chief complaint
the nurse is teaching the student nurse how to perform a physical assessment based on the child’s developmental stage. which statement accurately describes a recommended guideline for setting the tone of the examination for a school age child?
include the child in all parts of the examination; speak to the caregiver before and after the examination
which would be least effective in gaining the cooperation of a toddler during a physical examination?
tell the child another child the same age wasn’t afraid?
the nurse is performing a physical examination on a sleeping newborn. which body system should the nurse examine last?
throat
the nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. what is the appropriate order?
inspection, palpating, percussion, auscultation
the nurse is examining the posture of a man toddler and notes lordosis. what would be the appropriate reaction of the nurse to this finding?
do nothing; this is a normal condition for toddlers
lordosis: swayback
the nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. what would the best method to assess temperature in this child?
auxiliary method
the nurse is preparing to take a tympanic temperature reading of a 4 year old. in order to get an accurate reading, what does the nurse need to do?
direct the infrared sensor at the tympanic membrane
a mother bring her 3 year old daughter to the er because the child has been vomiting and having diarrhea for the past 36 hours. when assessing this child’s temp, which method would be least appropriate
rectal
the nurse is assessing heart rate for children on the pediatric ward. wha this a normal finding based on developmental age?
an infants rate is 90 bpm
normal infant: 80-150 bpm
toddler: 70-120
preschool: 65-110
school age: 60-100
the nurse is assessing the heart rate of a healthy school aged child. the nurse expects that child’s heart rate to be in what range
60-100
the nurse is preparing to assess the pulse of an 18 month old child. which pulse would be most difficult for the nurse to palpate?
radial
while auscultating the heart of a 5 year old. the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultate. the nurse documents this finding as what grade?
grade 2
the parents of a 2 day old girl are concerned because her feet and hands are slightly blue. how should the nurse respond?
this is normal; her circulatory system will take a few days to adjust
a nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. what do these findings indicate
these are normal findings
the nurse is assessing the neck of an 8 year old child with down syndrome. which finding would the nurse expect during the examination?
lax neck skin
the nurse is conducting a routine health assessment of a 3 month old boy and notices a flat occiput. the nurse provides teaching and emphasizes the importance of tummy time. which response by the mother indicates a need for further teaching?
I should have him sleep on his tummy
the nurse is measuring the blood pressure of a 12 year old boy with an oscillometric device. the boy’s reading is greater than the 90th percentile for gender and height. what is the appropriate nursing action?
repeat the blood pressure using auscultation
the nurse is inspecting the fingernails of an 18 month old girl. what finding indicated hypoxemia?
clubbing of the nails
the nurse is using pulse oximetry to measure oxygen saturation in a 3 year old girl. the nurse understands that falsely high readings may be associated with which situation or condition?
anemia
assessment reveals that a child weighs 73 lb and is 4 ft 1 in tall. the nurse calculates teh BMI as
21.4
BMI= [weight (lbs) / height (in)]^2 x 703
the nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. what may be associated with renal disorders?
observation of a supernumerary nipple along the mammary ridge
the nurse is inspecting the genitalia for a prepubescent girl. which is a normal sign of the onset of puberty?
appearance of pubic hair around 11-13 years old
a teenage client tells the nurse that she is being abused by her boyfriend, but she doesn’t want her parents to know because they won’t let her see him any longer. what is the best response of the nurse?
I understand your fear, but i am obliged to be sure your parents know that you are in danger. would you like for use to talk to them together?
the nurse is collecting information from the parents of a 3 year old child about her sleeping patterns. which question by the nurse will best elicit information form the parents
how many hours does your child sleep at night
