Deck 25: Assessment of Infants, Children Adolescents

Question 1

The nurse is assessing the newborn and notes the presence of a bluish discoloration of the hands and feet.Which of the following actions would be most important for the nurse to perform next?
1)Assess the oral mucosa.
2)Obtain the newborn's temperature.
3)Apply a blanket.
4)Assess capillary refill.

Answer 1

1

Question 2

The child has been diagnosed with acute otitis media.Which of the following findings by the nurse are consistent with this diagnosis?
1)Temperature is 101.4 degrees Fahrenheit.
2)The tympanic membrane is pearly gray.
3)The mother states,"I cannot get her to eat anything.She just picks at her food."
4)The mother states,"She has been so fussy."
5)The mother states,"She can sleep only while she's sitting up on my lap while I'm in the rocking chair."

Answer 2

1,3,4,5

Question 3

The nurse is interviewing the mother of a 6 month old during a well-child visit.The mother reports that there is a watery drainage from the infant's left eye with some crusting present within the eyelashes.The nurse inspects the infant's left eye and agrees with the mother's assessment.In which of the following ways would the nurse accurately document this finding?
1)Exotropia
2)Esotropia
3)Dacryostenosis
4)Congenital cataracts

Answer 3

3

Question 4

The nurse is assessing a newborn and notes that the infant has six fingers on the left hand.The nurse would accurately document this information in which of the following ways?
1)Syndactyly
2)Polydactyly
3)Brachial plexus injury
4)Erb's palsy

Question 5

The nurse is preparing to perform an assessment on four children.After reviewing each child's admitting diagnosis,which of the following children may have an enlarged spleen?
1)14 year old admitted with acute gastroenteritis
2)17 year old admitted with an acute exacerbation of asthma
3)11 year old admitted with an umbilical hernia
4)9 year old admitted with a sickle cell crisis

Question 6

The 5-year-old child's mother asks how much her child's bladder can hold.She states,"It seems like if we visit my mother who lives 2 hours away,we always have to stop once so that my child can pee.I just wondered how big his bladder may be." Calculate the maximum amount of urine that the child can hold within the bladder in milliliters.
________ milliliters

Question 7

The mother of a 17-year-old female has brought her daughter in for an examination.Which of the following statements by the client is most consistent with the client's most likely diagnosis?
1)"I usually just feel so tired."
2)"I've been growing this strange,soft,light-colored 'fur' all over."
3)"Everyone says I'm thin,but I don't feel like I look thin."
4)"I perspire all of the time and my skin is so oily."
5)"I'm sorry,but I cannot get warm.Can you turn up the heat in this place?"

Question 8

The nurse is performing an otoscopic examination in a child and notes the child expressing pain as the pinna is manipulated to better examine the tympanic membrane.Which of the following findings is consistent with the most likely condition?
1)Erythema is noted along the child's ear canal.
2)The tympanic membrane is in a full position,amber-colored,and immobile.
3)The external ear is abnormally protruding forward.
4)Edema is noted within the child's ear canal.
5)Light yellow drainage is noted within the ear canal.

Question 9

The nurse is assessing the child and notes that there is a depression in the lower part of the sternum.The nurse would accurately document this finding in which of the following ways?
1)Normal sternal border
2)Pectus carinatum
3)Barrel chest
4)Pectus excavatum

Question 10

An 18-month-old child is brought to the emergency room with difficulty breathing.The physician diagnoses the child with epiglottitis.Which of the following findings by the nurse are consistent with this diagnosis?
1)Oxygen saturation level is 85% on room air.
2)Respiratory rate is 22 per minute.
3)Stridor is audible without stethoscope.
4)Apical heart rate is 72 beats per minute.
5)Temperature is 103.7 degrees Fahrenheit.

Question 11

The mother of a 7-year-old child states,"I'm concerned because I can feel a few lumps at the base of his neck." The nurse notes slightly enlarged,firm,nontender,cervical lymph nodes.The lymph nodes are easily moveable under the skin.Which of the following interventions would be appropriate?
1)Speak with the physician about acquiring a throat culture.
2)Assess the client's temperature.
3)Examine the child's tonsils for tonsillitis.
4)Explain to the mother that this is a normal finding.

Question 12

The child has been admitted to the Intensive Care Unit following a motor vehicle accident.The child weighs 39 pounds.Calculate the child's minimum expected urinary output in milliliters over an 8-hour period.Round to the nearest whole number.
__________ milliliters

Question 13

The nurse is examining a child.The child's pharynx is reddened,with yellow exudate noted on each tonsil.The tongue is red with enlarged taste buds.Petechiae are visualized on the child's soft palate near the uvula.Which of the following physician orders is most important and appropriate for this child?
1)Saline mouth rinses
2)Throat culture
3)Dental referral
4)Aspirin for pain

Question 14

The nurse is assessing a newborn and abducts the hips and palpates the greater and lesser trochanter while flexing the hips and knees at a 90-degree angle.The nurse is assessing which of the following?
1)Barlow's maneuver
2)Knee fracture
3)Galeazzi sign
4)Ortolani's maneuver

Question 15

The parents of a 3-year-old child with a history of frequent otitis media incidences ask the nurse why their child continues to have this issue.Which of the following is the nurse's best response?
1)Children of this age frequently put things in their ears.
2)The eustachian tubes are shorter,more level,and straighter in children this age.
3)Children of this age experience more difficulty washing their hands appropriately.
4)The child has a hearing problem that is causing this to occur more frequently.

Question 16

The nurse has assessed a 7-year-old female.The child has a moderate amount of pubic and axillary hair.The mother states,"I just think she is going through puberty early.I was 11 when I went through these changes." The nurse's best response would be:
1)"Your daughter is very young to be experiencing these types of changes."
2)"You are probably right,since you went through these types of changes early."
3)"This type of hair growth is normally associated with cardiovascular disorders."
4)"Are her friends experiencing the same changes?"

Question 17

The nurse is performing an assessment on a 13-year-old adolescent.Which of the following findings would be unexpected?
1)Apical heart rate of 110 beats per minute
2)Respiratory rate of 14 breaths per minute
3)Blood pressure of 98/58
4)Temperature of 98.8 degrees Fahrenheit

Question 18

The nurse is performing an assessment of a 7 month old.Which of the following findings may be unexpected?
1)The anterior fontanelle is closed.
2)The posterior fontanelle is closed.
3)The head is disproportionately large in comparison to the body.
4)There are two "baby teeth" present.

Question 19

The nurse needs to assess the young child's gait and range of motion of the extremities.Which of the following instructions is a commonly used method during this portion of the child's assessment?
1)"I need you to pretend to be a duck.Squat and move forward while flapping your arms."
2)"Let me see you jump in place on both feet."
3)"Please hop across the room on one foot and then come back by hopping on the other foot."
4)"Would you please do some jumping jacks for me?"

Question 20

The nurse is assessing a newborn when the mother asks about the tiny white "bumps" on the forehead and nose.The nurse would respond to the mother with which of the following statements?
1)"Those are milia and they are very common."
2)"That is lanugo and it is very common."
3)"Those are Mongolian spots."
4)"Those are salmon patches."

Question 21

The nurse is performing an assessment on the following 5 newborns.Which of the newborns does the nurse expect to exhibit Mongolian spots?
1)African American newborn
2)Caucasian newborn
3)Hispanic newborn
4)Native American newborn
5)Asian newborn

Question 22

The 15 month old has been diagnosed with acute otitis media.Which of the following nursing diagnoses would be most applicable?
1)Acute pain
2)Hyperthermia
3)Nutrition: altered,more than body requirements
4)Risk for caregiver role strain
5)Decreased cardiac output

Question 23

The nurse is performing an otoscopic examination of a 3-year-old child.As the nurse prepares to examine the client's tympanic membrane with the ototscope,the nurse would correctly choose which of the following techniques?
1)Pull the tragus up and back while inserting the otoscope.
2)Pull the ear lobe up and back while inserting the otoscope.
3)Pull the ear lobe down and back while inserting the otoscope.
4)Pull the tragus down and back while inserting the otoscope.

Question 24

The nurse is educating the child's parents about the importance of limiting the child's intake of fruit juice to less than 12 ounces each day.Calculate the number of ounces the child has had during the last 24 hours.
120 milliliters of orange juice,60 milliliters of grape juice,90 milliliters of cranberry-grape juice _____ ounces

Question 25

The student nurse is preparing to perform an assessment on a 5-year-old Arab American child with a possible case of otitis media.The experienced nurse accompanies the student nurse.Which of the following statements by the student nurse indicate that further education is required?
1)"It would be best to have the child sit in his mom's lap if we have to give him a shot."
2)"Before I listen to the child's lungs,I can let him play with my stethoscope."
3)"I will be able to see the tympanic membrane more clearly if I pull the tragus down and back."
4)"It really doesn't matter what his culture is;mommies always make the decisions about children's health care issues."
5)"I'm going to have to be firm but friendly with my approach to the child."

Question 26

The student nurse is preparing to provide care for several newborns and their families.The experienced nurse is present to ensure appropriate care is provided.Which of the following statements by the student nurse indicates that further education is required?
1)"The newborn's parents recently moved here from Mexico,so we need to ensure that the baby is tested for sickle cell anemia."
2)"When dealing with the Chinese parents,it is important to remember that they may not make a lot of direct eye contact when I'm talking with them."
3)"When dealing with the parents from Mexico,I must make sure that I do not touch the baby when I compliment him."
4)"The baby's parents were raised on the Indian reservation.We should make sure the baby is tested for hypothyroidism."

Question 27

The nurse has reviewed the objectives of Healthy People 2020 related to children's health issues.As the nurse looks through a magazine,several articles seem to be related specifically to the objectives.Which of the following articles are associated with these objectives?
1)The three best ways to keep your children safe from guns in your home.
2)Back to sleep,baby;the importance of placing your baby on his or her back to sleep.
3)A strong marriage means strong children.
4)My daughter wouldn't stop drinking while she was pregnant;how I helped her.
5)I am a teen and I took the pledge not to text and drive.

Question 28

The nurse determines that nutritional education is needed for the family of an 8 month old after the history reveals the following: the infant is drinking whole milk 3 times a day from a bottle,eats table food such as hot dogs and grapes with the 2-year-old sibling,and is allowed gum as a reward for good behavior.Which part of the data would the nurse be able to support as being correct for a child of this age?
1)Consumption of whole milk
2)Eating table foods such as hot dogs and grapes
3)Has been given gum for good behavior
4)Drinking from a bottle

Question 29

The nurse presented an educational program for parents regarding children and adolescent health issues noted specifically in Healthy People 2020.Following the program,the nurse listened to several people talking to each other about the contents of the program.Which of the following statements made by program participants indicate that further education is required?
1)"No one needs training to put in a car seat.Parents just need to buy them."
2)"As parents,we have to actively watch our children to make sure they remain safe."
3)"After that program,I realize that my 14 year old may need psychologic counseling for depression.I just thought he was in a blue funk,but he could actually try to commit suicide."
4)"Up until now,I've let older children swim alone without supervision.That is going to stop."

Question 30

The child is prescribed an antibiotic for an acute middle ear infection.The child weighs 38 pounds.The antibiotic is available as 200 milligrams in 5 milliliters.The physician writes an order for the child to receive 45 milligrams per 1 kilogram of body weight each day,divided in three equal doses.Calculate the amount of medicine the child should receive per dose.Round to the tenths place.
_______ milliliters