Deck 32: Health Assessment of Children

Question 1

The nurse is conducting a health history for a 9-year-old child with stomach pains. Which of the following is a recommended guideline when approaching the child for information?

A) Wear a white examination coat when conducting the interview.
B) Allow the child to control the pace and order of the health history.
C) Use quick deliberate gestures to get your point across.
D) Do not make physical contact with the child during the interview.

Answer 1

Allow the child to control the pace and order of the health history.

Question 2

For which of the following children would the nurse conduct an immediate comprehensive health history?

A) A child who is brought to the emergency room with lacerations
B) A child who is a new client in a pediatric office
C) A child who is a routine client and presents with signs of a sinus infection
D) A child whose condition is improving

Answer 2

A child who is a new client in a pediatric office

Question 3

The nurse is performing a health history on a 6-year-old boy who is having trouble adjusting to school. Which of the following questions would be most likely to elicit valuable information?

A) "Do you like your new school?"
B) "Are you happy with your teacher?"
C) "Do you enjoy reading a book?"
D) "What are your new classmates like?"

Answer 3

"What are your new classmates like?"

Question 4

The nurse performing a health history on a child asks the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question?

A) Endocrine
B) Genitourinary
C) Hematologic
D) Neurologic

Question 5

The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which of the following topics might the nurse include? Select all answers that apply.

A) The child's toileting habits
B) Use of car seats and other safety measures
C) Problems with growth and development
D) Prenatal and perinatal history
E) The child's race and ethnicity
F) Use of supplements and vitamins

Question 6

The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?

A) The child
B) The parents
C) Chief complaint
D) Developmental age

Question 7

The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which of the following statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child?

A) Keep up a running dialogue with the caregiver, explaining each step as you do it.
B) Include the child in all parts of the examination; speak to the caregiver before and after the examination.
C) Speak to the child using mature language and appeal to his or her desire for self- care.
D) Address the child by name; speak to the caregiver and do the most invasive parts last.

Question 8

Which of the following would be least effective in gaining the cooperation of a toddler during a physical examination?

A) Tell the child that another child the same age wasn't afraid.
B) Allow the child to touch and hold the equipment when possible.
C) Permit the child to sit on the parent's lap during the examination.
D) Offer immediate praise for holding still or doing what was asked.

Question 9

The nurse is performing a physical examination on a sleeping newborn. Which of the following body systems should the nurse examine last?

A) Heart
B) Abdomen
C) Lungs
D) Throat

Question 10

The nurse is examining the posture of a male toddler and notes the condition "lordosis." What would be the appropriate reaction of the nurse to this finding?

A) Explain that the child will need a back brace.
B) Refer the toddler to a physical therapist.
C) Do nothing; this is a normal condition for toddlers.
D) Notify the primary care physician about the condition.

Question 11

The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child?

A) Oral thermometer
B) Axillary method
C) Temporal scanning
D) Rectal route

Question 12

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?

A) Pull the earlobe back and down
B) Direct the infrared sensor at the tympanic membrane
C) Pull the earlobe down and forward
D) Remove any visible cerumen from inside the ear canal

Question 13

A mother brings her 31/2-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child's temperature, which method would be least appropriate?

A) Oral
B) Tympanic
C) Rectal
D) Axillary

Question 14

The nurse is assessing heart rate for children on the pediatric ward. Which of the following is a normal finding based on developmental age?

A) An infant's rate is 90 bpm.
B) A toddler's rate is 150 bpm.
C) A preschooler's rate is 130 bpm.
D) A school-age child's rate is 50 bpm.

Question 15

The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which of the following sites to obtain an accurate assessment?

A) Radial pulse
B) Brachial pulse
C) Apical pulse at the third or fourth intercostal space
D) Apical pulse at the fourth or fifth intercostal space at the midclavicular line

Question 16

The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child's heart rate will be in which of the following ranges?

A) 80 to 150 bpm
B) 70 to 120 bpm
C) 65 to 110 bpm
D) 60 to 100 bpm

Question 17

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?

A) Radial
B) Brachial
C) Pedal
D) Femoral

Question 18

While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as which of the following?

A) Grade 1
B) Grade 2
C) Grade 3
D) Grade 4

Question 19

The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?

A) "Your daughter has acrocyanosis; this is causing her blue hands and feet."
B) "Let's watch her carefully to make sure she does not have a circulatory problem."
C) "This is normal; her circulatory system will take a few days to adjust."
D) "This is a vasomotor response caused by cooling or warming."

Question 20

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?

A) Increased intracranial pressure
B) Overhydration
C) Dehydration
D) These are normal findings.

Question 21

The nurse is assessing the neck of an 8-year-old child with Down syndrome. Which of the following findings would the nurse expect during the examination?

A) Webbing
B) Excessive neck skin
C) Lax neck skin
D) Shortened neck

Question 22

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 of the following responses by the mother indicates a need for further teaching?

A) "He must be positioned on his tummy as much as possible."
B) "I need to watch him during his tummy time."
C) "I need to change his head position while he is in an upright chair."
D) "His head has flattened due to the pressure of his head position."

Question 23

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?

A) Repeat the reading with the oscillometric device.
B) Repeat the blood pressure reading using auscultation.
C) Measure the blood pressure in all four extremities.
D) Measure the blood pressure with a Doppler.

Question 24

The nurse is inspecting the fingernails of an 18-month-old girl. Which of the following findings indicates chronic hypoxemia?

A) Nails that curve inward
B) Clubbing of the nails
C) Nails that curve outward
D) Dry, brittle nails

Question 25

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?

A) A nonsecure connection
B) Cold extremities
C) Hypovolemia
D) Anemia

Question 26

Assessment reveals that a child weighs 73 lb and is 4 ft 1 in. tall. The nurse calculates this child's body mass index as:

A) 19.1
B) 20.7
C) 21.4
D) 24.5

Question 27

The nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. Which of the following may be associated with renal disorders?

A) Swollen nipples upon inspection of a newborn's breasts
B) Tender nodule palpated under the nipple of a 10-year-old
C) Observation of enlarged breast tissue in a male adolescent
D) Observation of a supernumerary nipple along the mammary ridge

Question 28

The nurse is inspecting the genitals of a prepubescent girl. Which of the following are normal signs of the onset of puberty?

A) Appearance of pubic hair around 11 to 13 years old
B) Swelling or redness of the labia minora
C) Presence of a small amount of downy pubic hair
D) Lesions on the external genitalia