PEDS BOOK CH4 Flashcards
Which statement explains why it can be difficult to assess a child’s dietary intake?
No systematic assessment tool has been developed for this purpose.
Biochemical analysis for assessing nutrition is expensive.
Families usually do not understand much about nutrition.
Recall of children’s food consumption is frequently unreliable.
Recall of children’s food consumption is frequently unreliable.
It is difficult for parents to recall exactly what their child has eaten. Concurrent food diaries are somewhat more reliable. Systematic tools have been developed and are available. Nutrients for different foods are known; the quantity and type of food consumed are the facts that are difficult to ascertain. The family does not need nutritional knowledge to describe what the child has eaten.
Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation?
Palpate another area simultaneously.
Ask the child not to laugh or move if it tickles.
Begin with deeper palpation and gradually progress to superficial palpation.
Have the child “help” with palpation by placing his or her hand over the palpating hand.
Have the child “help” with palpation by placing his or her hand over the palpating hand.
Having the child “help” allows the nurse to perform the assessment while including the child in his or her care. Palpating another area simultaneously would not promote relaxation and would make it more difficult to perform the abdominal assessment. Asking a child not to laugh or move if it tickles may only contribute to the child’s laughter or may prove frustrating to both the child and the nurse. Deeper palpation will enhance the “tickling” sensation, not lessen it.
What is the most accurate method of determining the length of a child younger than 12 months of age?
Standing height
Estimation of length to the nearest centimeter or 1/2 inch
Recumbent length measured in the prone position
Recumbent length measured in the supine position
Recumbent length measured in the supine position
The crown–heel length measurement is the most accurate measurement in infants. Infants are generally unable to stand for obtaining a height measurement. Measurement should not be estimated, because an accurate measurement is required to determine growth. The infant should be measured in the supine position, not the prone position.
When interviewing a patient, which statement/action indicates that the nurse is displaying empathy?
The nurse offers the patient a tissue when the patient is crying after hearing some sad news before giving the patient medication.
The nurse and patient discuss their families and discover they each have two brothers.
The patient appreciates that the nurse has sat by her bedside and held her hand while they spoke about health concerns.
The nurse provided the patient’s family with Advanced Directive Form to fill out acknowledging that it has to be done in order to fulfill the patient’s wishes.
The patient appreciates that the nurse has sat by her bedside and held her hand while they spoke about health concerns.
Empathy convey that the person understands, is supportive and can view the situation from the other person’s perspective whereas sympathy is the acknowledgement of another person’s feelings or emotions without the context of understanding. Providing a tissue to a patient is an example of sympathy. Finding out that the nurse and patient have similar number of family members does not convey either empathy or sympathy but rather factual disclosure. The nurse providing an Advanced Directive Form is part of one’s nursing role.
Which observable behaviors would indicate to the nurse that the patient is experiencing information overload?
Select all that apply.
Fidgeting constantly while seated in the chair
A period of silence noted between a question
The patient wanting to continue talking about one subject of interest
The patient is yawning repeatedly
The patient is scanning the environment avoiding eye contact while the nurse is attempting to ask questions.
Fidgeting constantly while seated in the chair
The patient is yawning repeatedly
The patient is scanning the environment avoiding eye contact while the nurse is attempting to ask questions.
Examples of information include but are not limited to: constant fidgeting, repetitive yawning, and avoidance of eye contact while looking away from the interviewer and scanning the environment. A period of silence noted between one question is not in itself indicative of information overload unless the silence continues. The patient wanting to focus on one subject of interest is not associated with information overload.
Guidelines for a nurse using an interpreter in developing a care plan for an 8-year-old admitted to rule out epilepsy include
explaining to the interpreter what information is necessary to obtain from the patient and family.
encouraging the interpreter to ask several questions at a time to make the best use of time.
not giving the interpreter too much information so that the interview evolves.
discouraging the interpreter and client from discussing topics that are deemed irrelevant to the original intent of the interview.
explaining to the interpreter what information is necessary to obtain from the patient and family.
The interpreter should be given guidance as to what information is necessary to obtain during the interview.
One question should be asked at a time, leaving sufficient time for the family to answer. The interpreter should not have to guess what to ask and what information to obtain during the interview. The interpreter should gain as much information from the family as they are willing to share based on the questions posed. Limits should not be placed on the interview.
The most appropriate method for a nurse to use to view the tonsils and oropharynx of a 6-year-old child is to
ask child to open mouth wide and say “Ahh.”
ask child to open mouth wide, and then place tongue blade in the center back area of the tongue.
examine mouth when child is crying to avoid use of tongue blade.
pinch nostrils closed until child opens mouth, then insert tongue blade.
ask child to open mouth wide and say “Ahh.”
If the child is cooperative, the child can open the mouth and move the tongue around for the examiner. No tongue blade is necessary to visualize the tonsils and oropharynx if the child cooperates. During crying, there is insufficient opportunity to completely visualize the tonsils and oropharynx. It is traumatic to pinch the nostrils closed until the child opens the mouth. There is no reason to use such measures, especially with cooperative children.
An expectation of the patient in a health care setting in terms of charting and documentation is that?
Information will be shared only with physicians in the hospital or clinic setting regardless of whether they are taking care of the patient.
The use of nursing informatics requires that passwords be changed upon access to maintain patient confidentiality.
The patient is assured that anyone in the hospital facility can access their chart.
Safeguard systems are in place within the hospital or clinic setting to help maintain confidentiality of patient records.
Safeguard systems are in place within the hospital or clinic setting to help maintain confidentiality of patient records.
Safeguard systems are in place, regardless of the practice setting so as to assure that health care providers who access records do so to maintain confidentiality of patient records. Only health care providers that are involved in the patient’s care should be accessing their medical records. Nursing informatics is the application of computer usage with regard to health care information. Although password changes are a part of the safeguard integrity of systems, they are not typically changed with each access attempt.
The appropriate direction to pull the pinna of an infant during an otoscopic examination is
down and back.
down and forward.
up and forward.
up and back.
down and back.
The correct position for an infant’s ear examination is to pull the pinna down and back. Pulling the pinna down and forward is the correct position for a child age 3 years and over. Pulling the pinna up and forward will not allow sufficient visualization of the ear. Pulling the pinna up and back will not allow sufficient visualization of the ear.
When assessing a preschooler’s chest, the nurse would expect
respiratory movements to be chiefly thoracic.
anteroposterior diameter to be equal to the transverse diameter.
intercostal retractions on respiratory movement.
movement of the chest wall to be symmetric bilaterally and coordinated with breathing.
movement of the chest wall to be symmetric bilaterally and coordinated with breathing.
The preschool-aged child should have symmetric chest movement bilaterally and a coordinated breathing pattern. At this age, breathing is a coordinated function and is primarily abdominal or diaphragmatic. Thoracic breathing occurs in older children, particularly girls. The anteroposterior diameter is equal to the transverse diameter in infants. As the child grows, the chest normally increases in the transverse direction; therefore, the anteroposterior diameter is less than the lateral diameter. Intercostal retractions are indicative of respiratory distress.
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 to
use the small cuff.
use the large cuff.
use either cuff, using palpation method.
locate the proper-sized cuff before taking the blood pressure
locate the proper-sized cuff before taking the blood pressure.
To obtain an accurate blood pressure reading, it is preferable to use the proper-sized cuff. Therefore, locating one before taking the blood pressure is the best nursing action. The smaller cuff gives a falsely increased blood pressure and is not the method of choice. The larger cuff, which may give a falsely lowered blood pressure, is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice. Auscultation is preferred to palpation.
The nurse is interviewing the parents of a toddler and wants to determine the child’s feeding preferences during meal time. Which statement made by the nurse is an example of directed focus?
“I know we have discussed your son’s eating habits but can we now discuss what Sam like to eat for lunch?”
“How much time does it take for Sam to finish his meals?”
“Would Sam prefer hot dogs or chicken nuggets, if given a choice?”
“Would Sam prefer pudding as opposed to cake?”
“I know we have discussed your son’s eating habits but can we now discuss what Sam like to eat for lunch?”
Asking an open ended question following a statement help to direct the focus and obtain more information. The other provided options are examples of close-ended questions and as such would lead to a limited information related to specific findings of time and individual food preferences.
The nurse is ready to begin a physical examination on an 8-month-old infant. The child is sitting contentedly on the mother’s lap, chewing on a toy. What should the nurse do first?
Elicit reflexes.
Auscultate the heart and lungs.
Examine the eyes, ears, and mouth.
Examine the head, systematically moving toward the feet.
Auscultate the heart and lungs.
While the child is quiet, auscultation should be performed. It may disturb or upset the child to elicit reflexes first, making auscultation and the remainder of the physical examination difficult. It may disturb or upset the child to examine the eyes, ears, and mouth first, making auscultation and the remainder of the physical examination difficult. Although most physical examinations proceed from the head to the feet, the nurse should perform the assessment for a child in an order that moves from least disturbing to most disturbing from the child’s perspective.
Which physical assessment findings would be associated with the presence of alopecia?
Select all that apply.
Excess vitamin C Decreased protein intake Decreased caloric intake Decreased copper Decreased zinc
Decreased protein intake
Decreased caloric intake
Decreased zinc
The presence of alopecia could be related to decreases in protein and caloric intake. It is also associated with decreased intake of zinc. Decreased intake of zinc is associated with depigmentation. Excess vitamin C can be associated with pallor.
For which scenario would the expectation of confidentiality by the nurse not be withheld during an interview format?
Select all that apply.
15-year-old emancipated minor who wants to discuss birth control methods
14-year-old patient who denies abuse but who presents with multiple bruises over arms and legs which appear to be “defensive type” in nature
16-year-old patient who appears sad and voices despair over having broken up with his boyfriend states he has no options
18-year-old patient who confides in the nurse that she wants to move out and get her own apartment
14-year-old patient who denies abuse but who presents with multiple bruises over arms and legs which appear to be “defensive type” in nature
Any patient should have the expectation during the interview process that the concept of confidentiality will be provided, regardless of age or gender. However, there are certain exceptions to the concept of confidentiality when there are perceived threats of either violence, self-directed or as a consequence of abuse. Nurses are legally required to report suspected evidence of abuse and/or actions related to suicide. An emancipated minor seeking birth control and an 18 year old who wishes to move out of her home and get an apartment are within the concept of confidentiality.
