Lecture 1 Health assessment of infants and children

Question 1

Health promotion

Answer 1

Giving the patient/family resources to meet needs and stay healthy.

Question 2

Health maintenance

Answer 2

Injury prevention and disease prevention (e.g., immunizations).

Question 3

Three external factors influencing pediatric healthcare

Answer 3

Community, culture, and family.

Question 4

Anticipatory guidance

Answer 4

Interventions by the nurse that are focused on providing families information on normal growth and development and nurturing childrearing practices, before potential problems occur.

Question 5

Erik Erikson’s psychosocial stages of development (pediatric only)

Answer 5

1. Birth to 1 year = Trust vs. mistrust.
2. 12 to 36 months = Autonomy vs. shame and doubt.
3. 3 to 6 years = Initiative vs. guilt.
4. 6 years to adolescence = Industry vs. inferiority.
5. Adolescence to adulthood = Identity vs. role confusion.

Question 6

Jean Piaget’s cognitive developmental theory

Answer 6

1. Birth to 24 months = Sensorimotor stage.
2. 2 to 7 years = Preoperational stage.
3. 7 to 11 years = Concrete operational stage.
4. 11 to 17 years = Formal operational stage.

Question 7

Infants

Answer 7

1. 0-1 year of age.
2. Nonverbal, crying/cooing, sensitive to parent’s presence - as much of assessment as possible can be done while the child is on the parent’s lap or in the parent’s arms. Sensitive to sounds and tone of voice. Undressing - have the parent undress the infant as needed.
3. Erikson: Trust vs. mistrust.
4. Piaget: Sensorimotor stage.

Question 8

Early childhood

Answer 8

1. 1-5 years of age; toddler and preschool.
2. Egocentric - focus communication on the child. Believe in animism (drawings and objects come to life), take things literally. Keep equipment out of sight until needed and provide simple, concrete explanations. Toddlers - stranger anxiety.
3. Erikson: Autonomy vs. shame and doubt (1-3 years), initiative vs. guilt (3-6 years).
4. Piaget: Sensorimotor stage (until 2 years), preoperational stage (2-7 years).

Question 9

School-age children

Answer 9

1. 5-12 years of age.
2. Increasing vocabulary, concerned about threats to body and separation, allow time for them to express fears and concerns. Interested in the functional aspects of procedures/equipment - provide simple explanations.
3. Erikson: Industry vs. inferiority.
4. Piaget: Preoperational stage (until 7 years), concrete operational stage (7-11 years).

Question 10

Adolescents

Answer 10

1. 12-20 years of age.
2. Be straightforward, respectful, nonjudgmental. Better understanding of abstract concepts. Likely to have body image concerns, may be sexually active.
3. Erikson: Identity vs. role confusion.
4. Piaget: Formal operational stage.

Question 11

Measuring height

Answer 11

From 0-36 months, measure laying down. From 2-18 years, measure standing up.

Question 12

Taking temperature

Answer 12

1. Birth to 2 years: Axillary temperature (always).
2. After 2 years: May take axillary, tympanic, or oral temperature (if tolerated).
3. Rectal temperatures not taken without MD order - usually only used when accuracy is essential.

Question 13

Pulse

Answer 13

1. Higher rate than adults.
2. All pediatric patients: Apical pulse, taken for 1 full minute. Satisfactory radial pulses can be taken in children older than 2 years.
3. Grade peripheral pulses (0 to +4).
4. Compare radial and femoral at least once during infancy (upper to lower extremities).

Question 14

Respirations

Answer 14

1. Higher rate than adults.
2. Count for 1 full minute because irregular breathing is common in children.
3. Infants - diaphragmatic breathers; observe the abdomen rather than the chest (becomes thoracic around 6-7 years).

Question 15

Blood pressure

Answer 15

1. Both systolic and diastolic are lower than in adults.
2. Auscultation, rather than automated devices, is preferred unless auscultation is difficult (e.g., newborns).
3. The cuff should cover approximately 2/3 of the upper arm or at least 40% of the arm circumference.

Question 16

The posterior fontanel closes by _

Answer 16

6-8 weeks.

Question 17

The anterior fontanel closes by _

Answer 17

18 months.

Question 18

Infants normally attain head control by _

Answer 18

5 months.

Question 19

The top of the pinnae should be aligned with _

Answer 19

The lateral canthi of the eyes (low-set ears may be indicative of certain genetic disorders).

Question 20

Inner ear examination

Answer 20

Until age 3: Pull the pinna down and back.

After age 3: Pull the pinna up and back.

Question 21

Adequate urine output for a child

Answer 21

1 mL/kg/hr.

Question 22

Wong-Baker FACES Pain Scale

Answer 22

Can be used for children as young as 3 years. Six cartoon faces ranging from a smiling face for “no pain” to a tearful face for “worst pain.” The child is asked to choose a face that describes his or her pain.

Question 23

FLACC Postoperative Pain Tool

Answer 23

(An observational scale for post-op pain used from 2 months to 7 years.)
Facial expression
Leg movement
Activity
Cry
Consolability

Question 24

CRIES Neonatal Postoperative Pain Scale

Answer 24

Crying
Requires increased oxygen
Increased vital signs
Expression
Sleeplessness

Question 25

The single most important factor to consider when communicating with children is _

Answer 25

The child’s developmental level.

Question 26

The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active?

Answer 26

Ask her, “Are you having sex with anyone?” [Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information for the nurse to provide necessary care. The word “anyone” is preferred to using gender-specific terms such as “boyfriend” or “girlfriend.”]

Question 27

When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?

Answer 27

Providing sufficient amino acids. [A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth.]

Question 28

Which parameter correlates best with measurements of total muscle mass?

Answer 28

Upper arm circumference. [Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body’s major protein reserve and is considered an index of the body’s protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skinfold thickness is a measurement of the body’s fat content.]

Question 29

With the National Center for Health Statistics criteria, which body mass index (BMI)–for-age percentiles should indicate the patient is at risk for being overweight?

Answer 29

85th percentile. [Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits.]

Question 30

The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?

Answer 30

Use the large cuff. [If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure.]

Question 31

The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child’s head (opisthotonos) with pain on flexion. Which is the most appropriate action?

Answer 31

Refer for immediate medical evaluation. [Hyperextension of the child’s head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag.]

Question 32

Which explains the importance of detecting strabismus in young children?

Answer 32

Amblyopia, a type of blindness, may result. [By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes “lazy,” and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur.]

Question 33

The Ishihara Vision Test is used for _

Answer 33

Color vision.

Question 34

The nurse is testing an infant’s visual acuity. By which age should the infant be able to fix on and follow a target?

Answer 34

3-4 months.

Question 35

During an otoscopic examination on an infant, in which direction is the pinna pulled?

Answer 35

Down and back. [In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 o’clock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 o’clock position.]

Question 36

What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?

Answer 36

Pure tone audiometry. [Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the child’s ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.]

Question 37

What is the appropriate placement of a tongue blade for assessment of the mouth and throat?

Answer 37

Side of the tongue. [The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization.]

Question 38

A-P and transverse diameters

Answer 38

The anteroposterior diameter is equal to the transverse diameter during infancy. As the child grows, the chest increases in the transverse direction, so that the anteroposterior diameter is less than the lateral diameter.

Question 39

When auscultating an infant’s lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as?

Answer 39

An abnormal finding warranting further investigation. [Absent or diminished breath sounds are always an abnormal finding. Fluid, air, or solid masses in the pleural space all interfere with the conduction of breath sounds.]

Question 40

Breath sounds over different lung fields

Answer 40

Vesicular - Heard over the entire surface of the lungs, with the exception of the upper intrascapular area and the area beneath the manubrium.
Bronchial - Heard only over the trachea near the suprasternal notch.
Bronchovesicular - Heard over the manubrium and in the upper intrascapular regions.

Question 41

Heart sounds

Answer 41

S1 = Closure of the tricuspid and mitral valves; louder near the apex.
S2 = Closure of the pulmonic and aortic valves; louder near the base.
S3 = Normal heart sound sometimes heard in children.
S4 = Rarely heard as a normal heart sound - medical evaluation required.
Physiologic splitting = The distinction of the two sounds in S2, which widens on inspiration; a significant normal finding.

Question 42

During examination of a toddler’s extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which?

Answer 42

Normal because the lower back and leg muscles are not yet well developed. [Lateral bowing of the tibia (bowlegged) is an expected finding in toddlers when they begin to walk. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African American children.]