Question 1

The nurse is beginning a health history with a 3-year-old child. Which question should the nurse ask the mother first when beginning the history?

Accepted Answer

The most appropriate question to begin a health history is open ended. This type of question allows the parent to elaborate on the health of the child. Close-ended questions such as asking if the child has been ill or if the child has been ill in the past limit the amount of information learned for the history. Expansive statements such as "tell me about your daughter" are too vague.

Question 2

The nurse is identifying ways to support the 2020 National Health Goals during the upcoming preschool health screening program. What should the nurse include when conducting the program? (Select all that apply.)

Accepted Answer

To support the 2020 National Health Goals related to health assessment of children, the nurse should participate actively in health assessment, including vision and hearing, and screening for and administering vaccines. Listening to heart sounds and measuring gait and balance do not support the 2020 National Health Goals related to health assessment of children.

Question 3

The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information?

Accepted Answer

The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day. Day histories are fun to obtain because most parents are eager to describe their day with their child, and information gained this way is surprisingly rich and pertinent, much more so than if parents are just asked how their child sleeps, eats, or plays.

Question 4

The nurse is preparing to measure the head circumference of a 6-month-old child. How should the nurse make this measurement?

Accepted Answer

Head circumference is measured by placing a tape measure around an infant's head just above the eyebrows and around the most prominent portion of the back of the head or the occipital prominence. Head circumference is not measured using the hairline or the forehead.

Question 5

The nurse is preparing to assess the abdomen of a preschool age child. Which technique should the nurse use first?

Accepted Answer

To assess an abdomen, first inspect the surface for symmetry and contour. After inspection, the nurse should auscultate for bowel sounds. The examination concludes with percussion and palpation.

Question 6

The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this patient?

Accepted Answer

Rhonchi are snoring sounds that are made by air moving through mucus in the bronchi. This is a normal sound. Stridor is a crowing sound being made through a constricted larynx. This is an abnormal sound. Crackles are sounds made by air moving through fluid. This is an abnormal sound. Wheezing is a whistling sound made by air moving through a narrow bronchus. This is an abnormal sound.

Question 7

The nurse is preparing care for a preschool-age child scheduled for a health history and physical assessment. At which point will the nurse determine nursing diagnosis appropriate for the child's care?

Accepted Answer

Nursing diagnosis related to health assessment most commonly address a health concern identified at the time of the assessment. When establishing nursing diagnoses, do not overlook diagnoses that accentuate the healthy functioning of a child and family, even when diagnoses that address specific problems have been identified. Wellness diagnoses are crucial components of the entire assessment picture. The nurse cannot identify diagnoses before the assessment occurs.

Question 8

The nurse is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this patient?

Accepted Answer

Blood pressure measurement begins to be a part of routine assessment at 3 years of age. The preschool E-chart is used for vision screening at this age. Walking gait and standing height measurement will be introduced in future assessments.

Question 9

During a previous well-child visit, the nurse reviews the importance of immunizations for the preschool-age child with the parents. Which outcome indicates that the nurse's instruction to the parents has been effective?

Accepted Answer

One of the most important health assessment and promotion measures for children is to establish their immunization status is up to date. The nurse should teach parents about the importance of having their children immunized and the need to be able to describe the record of immunizations a child has received. If gaps are present in a child's number of immunizations, remind the child's primary care provider about this lack in protection and prepare to administer the necessary vaccines. The child's immunizations begin up to date indicate that the nurse's instruction has been effective. Having the child immunize within a year might expose the child to pathogens than could be avoided. Children will cry when receiving injections. This is not a valid reason to postpone immunization. The health care provider needs to understand the importance of childhood immunizations to be received at the correct age and time.

Question 10

The nurse is preparing to conduct the cover test with a preschool-age child. Which body system is the nurse preparing to assess?

Accepted Answer

A screening procedure to determine eye alignment is the cover test. The cover test is not used to assess the ears, nose, or neck.

Question 11

The nurse is preparing to administer the Denver II Developmental Screening Test to a preschool-age child. Which areas of the child's development should the nurse explain to the mother that this test measures? (Select all that apply.)

Accepted Answer

The Denver II Developmental Screening Test is the most widely used tool to assess early childhood development and rates the categories of personal-social, fine motor-adaptive, language, and gross motor skills. The nurse should explain to the parent before administering the test that this test does not measure intelligence but of the child's level of development or ability to perform age-appropriate tasks.

Question 12

When conducting the Rinne test for hearing with a school-age child, the nurse learns that the child is unable to hear the sound when the tuning fork is moved to the auditory meatus. What does this finding suggest to the nurse?

Accepted Answer

The Rinne test is conducted by placing the stem of a tuning fork against the mastoid bone. When the sound disappears the fork is then moved to the auditory meatus. If the sound cannot be heard at the auditory meatus, this means air conduction of sound is impaired. This does not mean that bone conduction of sound is impaired. This does not mean that the child has normal hearing. This also does not mean that the child is totally deaf.

Question 13

The nurse is preparing to assess a school-age child who is experiencing pain in the left femur area. When conducting this assessment, at which point should the nurse assess the painful region?

Accepted Answer

If a child has a sensitive or painful body part, palpate that area last. Otherwise, the child may be unwilling to allow other parts to be touched in fear of additional pain. The painful regions should not be assessed first, after measuring vital signs, or before the abdominal assessment.

Question 14

When beginning a physical examination of a toddler, the nurse notes that the child has halitosis. On which body areas should the nurse focus when conducting the assessment? (Select all that apply.)

Accepted Answer

Halitosis or bad breath is considered a significant body odor, which could be caused by poor dental hygiene, a lung infection, or a foreign body in respiratory tract. The nurse should focus the assessment on the lungs and the oral cavity. The urinary tract, reflexes, and abdomen will not help determine the cause for the patient's halitosis.

Question 15

The nurse is planning an education session for adolescent males on health promotion activities. Which topic should the nurse include as being the most applicable for this population?

Accepted Answer

Starting in adolescence, all males need to perform testicular self-examination once a month. This is the health promotion activity in which the nurse should focus for this educational session. The reproductive cycle might be more appropriate for adolescent females. Immunization schedule and socialization would be more appropriate for younger children and parents.

Quiz 34: Child Health Assessment