Question 1

Which tool measures body fat most accurately?

Accepted Answer

Calipers are used to measure skin-fold thickness,which is an indicator of body fat content.Stadiometers are used to measure height.Cloth tape measures should not be used because they can stretch.Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.

Question 2

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

Accepted Answer

Asking the adolescent girl if she is having sex with anyone is a direct question that is easy to understand.The phrase sexually active is broadly defined and may not give specific enough information for the nurse to provide the necessary care.The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend,because homosexual experimentation may occur.Questioning about sexual activity should occur when the adolescent is alone.

Question 3

According to the WHO Growth Reference Charts,which body mass index (BMI)-for-age percentile indicates a risk for being overweight?

Accepted Answer

The 2007 WHO Growth Reference Charts include data that reflect healthy growth and can be used to identify children who are at risk for obesity.Children who have BMI-for-age greater than or equal to the ninetieth percentile are at risk.Children in the tenth and twenty-fifth percentiles are within normal limits.Children who are greater than or equal to the ninety-fifth percentile are considered overweight.

Question 4

What is an important consideration for the nurse who is communicating with a very young child?

Accepted Answer

Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse),facilitating communication.Speaking loudly,clearly,and directly tends to increase anxiety in very young children.The nurse must be honest with the child.Attempts at deception lead to a lack of trust.Whenever possible,a parent should be present for interactions with young children.

Question 5

Which is an appropriate approach to performing a physical assessment on a toddler?

Accepted Answer

Parents can remove clothing,and the child can remain on the parent's lap.The nurse should use minimum physical contact initially in order to gain the child's cooperation.The head-to-toe assessment can be done in older children but usually must be adapted for younger children.Traumatic procedures should always be performed last because they will most likely upset the child and inhibit cooperation.The nurse should introduce the equipment slowly.The child can inspect the equipment,but demonstrations are usually too complex for this age group.

Question 6

What approach is most likely to encourage parents to talk about their feelings related to their child's illness?

Accepted Answer

Closed-ended questions should be avoided when attempting to elicit parents' feelings.Open-ended questions require the parent to respond with more than a brief answer.Sympathy is defined as having feelings or emotions in common with another person,rather than understanding those feelings (which is called empathy).Sympathy is not therapeutic in the helping relationship.Direct questions may only obtain limited information.In addition,the parent may consider them threatening.Silence can be an effective interviewing tool.It allows two or more people to share feelings and absorb one another's emotions in depth.Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.

Question 7

What is the single most important factor to consider when communicating with children?

Accepted Answer

The nurse must be aware of the child's developmental stage to engage in effective communication.An understanding of the typical characteristics of these stages provides the nurse with a framework to facilitate social communication.The use of both verbal and nonverbal communication should be appropriate to the developmental level.Although the child's physical condition is a consideration,developmental level is much more important.The parents' presence is important when communicating with young children,but it may be detrimental when speaking with adolescents.Nonverbal behaviours vary in importance,based on the child's developmental level.

Question 8

The nurse is interviewing the mother of an infant.She reports,"I had a difficult delivery,and my baby was born prematurely." This information should be recorded under which heading?

Accepted Answer

The birth history is information that relates to previous aspects of the child's health,not to the current problem.The mother's difficult delivery and prematurity are important parts of an infant's past history.The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present.Unless the chief complaint is directly related to the prematurity,this information is not included in the history of present illness.The chief complaint is the specific reason for the child's visit to the clinic,office,or hospital,and would not include birth information.The review of systems is a specific review of each body system and does not include premature birth.Sequelae such as pulmonary dysfunction would be included.

Question 9

When introducing hospital equipment to a preschooler who seems afraid,which principle should the nurse keep in mind?

Accepted Answer

Young children attribute human characteristics to inanimate objects.They often fear that an object may jump,bite,cut,or pinch all by themselves without human direction.Equipment should be kept out of sight until needed.The nurse should give the child simple,concrete explanations about what the equipment does and how it will feel to help alleviate the child's fear.Preschoolers will need repeated explanations for reassurance.

Question 10

An 8-year-old girl asks the nurse how the blood pressure apparatus works.What is the most appropriate act for the nurse to take?

Accepted Answer

School-age children require explanations and reasons for everything.They are interested in the functional aspect of all procedures,objects,and activities.It is appropriate for the nurse to explain how equipment works and what will happen to the child.The nurse should respond positively to requests for information about procedures and health information.By not responding,the nurse may be limiting communication with the child.The child is not exhibiting anxiety,just requesting clarification about what will be occurring.The nurse must explain how the blood pressure cuff works ahead of time so the child can then quietly observe during the procedure.

Question 11

Which parameter correlates best with measurements of the body's total protein stores?

Accepted Answer

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,and weight is indicative of current nutritional status.Skin-fold thickness is a measurement of the body's fat content.

Question 12

Where in the health history should the nurse describe all the details related to the chief complaint?

Accepted Answer

The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present.The focus of the present illness is on all factors relevant to the main problem,even if they have disappeared or changed during the onset,at different intervals,and in the present.Past history refers to information that relates to previous aspects of the child's health,not to the current problem.The chief complaint is the specific reason for the child's visit to the clinic,office,or hospital;it does not contain the narrative portion describing the onset and progression.The review of systems is a specific review of each body system.

Question 13

Which statement describes the emerging illocutionary stage?

Accepted Answer

The emerging illocutionary stage (8-9 to 12-15 months)is when the child communicates intentionally with signals and gestures.The child reflexive to stimuli and showing increasing purpose in action is in the perlocutionary stage.The child communicating intentionally with vocalizations and verbalizations is in the conventional illocutionary-emerging locutionary stage.

Question 14

Which behaviour indicates to the nurse that the patient is experiencing information overload?

Accepted Answer

Nervous habits,such as playing with one's hair,are a sign that the patient has information overload.Other signs include avoiding eye contact,wide eyes,and attempting to change the topic of discussion.

Question 15

A nurse is taking the health history of an adolescent.Which statement best describes how to determine the chief complaint?

Accepted Answer

The chief complaint is the specific reason for the adolescent's visit to the clinic,office,or hospital.The adolescent is the focus of the history,so this is an appropriate way to determine the chief complaint.A list of symptoms will make it difficult to determine the chief complaint.The nurse should prompt the adolescent to state which symptom caused him to seek help at this time.The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help.The parent and adolescent may be interviewed separately,but the nurse should determine the reason the adolescent is seeking attention,not the parent.

Question 16

Which age group is most concerned with body integrity?

Accepted Answer

School-age children have heightened concerns about body integrity.They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggests injury.Body integrity is not as important to children in the toddler,preschooler,and adolescent age groups.

Question 17

The nurse is seeing an adolescent boy and his parents in the clinic for the first time.What should the nurse do first?

Accepted Answer

The first thing that nurses must do is introduce themselves to the patient and family.Parents and other adults should be addressed with appropriate titles unless they specify a preferred name.During the initial part of the interview,the nurse should include general conversation to help make the family feel at ease.Next,the purpose of the interview and the nurse's role should be clarified.The interview should take place in an environment as free of distraction as possible.In addition,the nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality.

Question 18

The nurse is having difficulty communicating with a hospitalized 6-year-old child.What technique is most helpful in improving communication?

Accepted Answer

Drawing is one of the most valuable forms of communication.Children's drawings tell a great deal about them because they are projections of the child's inner self.It would be difficult for a 6-year-old child to keep a diary,since the child is most likely just learning to read.Reading fairytales to the child is a passive activity involving the parent and child,and would not facilitate communication with the nurse.The child is in a stressful situation and is probably uncomfortable with strangers,not necessarily uncommunicative.

Question 19

When interviewing the mother of a 3-year-old child,the nurse asks about developmental milestones,such as the age when he started walking without assistance.How should milestones be considered?

Accepted Answer

It is important for the nurse to obtain information about the attainment of developmental milestones because they provide data about the child's growth that should be included in the history.Developmental milestones provide important information about the child's physical,social,and neurological health.The developmental milestones are specific to this child.If pertinent,attainment of milestones by siblings would be included in the family history.The review of systems does not include the developmental milestones.

Question 20

What is the most important thing for a nurse to say when interviewing an adolescent?

Accepted Answer

Adolescents,like all children,need an opportunity to express their feelings.Often they will inject feelings into their words.The nurse must be alert to both the words and feelings expressed.Although their peer group is important to those in this age group,the focus of the interview should be on the individual adolescent.The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality.The nurse should maintain a professional relationship with the adolescent.To avoid misinterpretation of words and phrases that the adolescent may use,the nurse should clarify terms frequently.

Quiz 33: Communication, History, Physical, and Developmental Assessment