The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most Show 1. "Does any member of your family have a history of asthma, heart disease, or diabetes?" Correct Answer: 3 Rationale 1: Asking the parents to talk about their concerns is an open-ended question and one which is more likely to establish rapport and an understanding of the parent's perceptions. Giving the family a list of items to answer at once may be confusing to the parents. Giving an introduction before asking the parents for information is likely to establish rapport, but giving an explanation of why the information would be needed would be even more effective at establishing rapport and also for getting more accurate, pertinent information. Simply asking the parents to fill out forms is very impersonal, and more information is likely to be obtained and clarified if the nurse is directing the interview. When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old? 1. Say the name of an object and after 5 minutes ask the child to tell you what you said the object was. Correct Answer: 2 Rationale 1: Repeating the name of an object after 5-10 minutes is assessing recent memory. Asking the child to repeat his address is assessing remote memory. Listening to speech articulation and pointing to body parts both assess communication skills. Place the nursing assessments of a toddler in the best order. Choice 1. Examination of eyes, ears, and throat Correct Answer: 4,2,3,1 Rationale 1: In examining a toddler, it is usually best to go from least invasive to most invasive examination in order to build her trust and cooperation. Developmental assessment involves visual inspection and activities that the toddler may view as games and will likely cooperate with. Auscultation is usually less threatening to the toddler than palpation, especially if the nurse were to use the stethoscope on a parent or a toy. The most uncomfortable, invasive exam for the toddler is most likely to be the examination of the eyes, ears, and throat, so that should be performed last. While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process? 1. Cardiac Correct Answer: 3 Rationale 1: This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system. Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system. Tenting of the skin and dry mucous membranes could be a sign of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system. A nurse caring for a school-age client notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate? 1. Skin integrity, especially in the lower extremities Correct Answer: 2 Rationale 1: Dependent, pitting edema, especially in the lower extremities, can be a symptom of both kidney and cardiac disorders. Decreases in urine output can also indicate compromise in both the renal and cardiac systems. Changes in level of consciousness, if present, would more than likely be a later effect in this situation. While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important. A new mother is worried about a "soft spot" on the top of her newborn infant's head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close? 1. 2 to 3 months of age Correct Answer: 3 Rationale 1: The anterior fontanel is located at the top of the head and is the opening at the intersection of the suture lines. As the infant grows, the suture lines begin to fuse, and the anterior fontanel closes at 12 to 18 months of age. While inspecting a 5-year-old child's ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority? 1. Temperature Correct Answer: 1 Rationale 1: Swelling behind an ear could indicate mastoiditis, and the presence of a fever would indicate a higher index of suspicion for this. There could also be changes in other vital-sign parameters, but they would not be specific for the presence of infection. A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? 1. Wheezing Correct Answer: 1,3,4 Rationale 1: Wheezing is caused by air passing through mucus or fluids in a narrowed lower airway, which is a condition present in asthma exacerbations. The air trapping in the lungs that occurs in asthma causes a decrease in the sensation of vibrations felt, not an increase in tactile fremitus, which is indicative of pneumonia. Bronchophony is an increase in the intensity and clarity of transmitted sounds. This is also indicative of pneumonia but not asthma, which causes a decrease in vocal resonance. The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order? 1. Tetralogy of Fallot Correct Answer: 3 Rationale 1: Normally, blood pressures in the lower extremities are the same as or higher than upper-extremity blood pressures. But in coarctation of the aorta, the narrowing of the aorta causes decreased blood flow to the lower extremities and thus lower-extremity blood-pressure readings are significantly lower than upper-extremity readings. There are minimal differences between upper and lower blood-pressure readings in tetralogy of Fallot, pulmonary atresia, and ventricular septal defect. During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action? 1. Recent memory Correct Answer: 3 Rationale 1: Asking children to remember addresses, phone numbers, and dates assesses remote-memory development. To evaluate recent memory the nurse would have the child name something and then ask him to name it again in 10 to 15 minutes. Listening to how the child talks and his sentence structure evaluates the child's language development, and assessing how he interacts with others evaluates social-skill development. During the newborn examination, the nurse assesses the infant for signs of developmental dysplasia of the hip. A finding that would strongly indicate this disorder would be: 1. soles are flat with prominent fat pads. Correct Answer: 4 Rationale 1: A positive Babinski reflex and flat soles are normal newborn findings. Metatarsus varus is an in- toeing of the feet that usually occurs secondary to intra-uterine positioning and frequently resolves on its own, but approximately 10 percent of infants with metatarsus varus also have developmental dysplasia of the hip. Asymmetric thigh and gluteal folds are a positive finding for developmental dysplasia of the hip requiring follow- up with ultrasound. The nurse must assess each of the 2-year-olds listed below. Which one should be evaluated first? 1. A child with a temperature of 101 degrees F Correct Answer: 2 Rationale 1: A child with stridor is at risk for airway compromise; a child with a temperature of 101 degrees F, while sick, is not as ill as the child with stridor; and the child with an absent Babinski sign and the pot-bellied child are normal. The nurse notes a history of a grade III heart murmur in a small infant. When assessing the heart, the nurse would expect to: 1. hear a quiet but easily heard murmur. Correct Answer: 2 Rationale 1: A quiet but easily heard murmur is a grade II. A moderately loud murmur without palpable thrill is a grade III. A very loud murmur with easily palpable thrill is a grade V. A murmur heard at the chest wall without the aid of a stethoscope is a grade VI. The nurse is measuring an abdominal girth on a child with abdominal distension. Identify the area on the child's abdomen where the tape measure should be placed for an accurate abdominal girth. 1. Just above the umbilicus, around the largest circumference of the abdomen Correct Answer: 1 Rationale 1: An abdominal girth should be taken around the largest circumference of the abdomen, in this case, just above the umbilicus. The circumference below the umbilicus or just below the sternum would not be an accurate abdominal girth. The nurse is preparing to assessment a toddler client. Which activities would gain cooperation from the toddler? Standard Text: Select all that apply. 1.
Asking the parents to wait outside Correct Answer: 2,4 Rationale 1: Allowing the client to stay on the parents lap and allowing the client to play with instruments that will be used in the assessment process are activities the nurse can implement to gain the toddler's cooperation during the assessment process. Asking the parents to wait outside may cause the toddler to become fearful. Vaccinations should be administered at the end of the visit. While making a game out of the assessment process may be appropriate for older children, this is not an appropriate strategy for a toddler client. The nurse is assessing an infant client during a health supervision visit.
Which assessment findings are considered normal variations for this client? 1. Sucking pads in the mouth Correct Answer: 1,2,3 Rationale 1: Normal variations for the infant client include sucking pads in the mouth, a rounded chest, and hearing breath sounds over the entire chest. Pubertal development and knock-knees are not normal variations for the infant client. The nurse is conducting a health surveillance visit with a 6-month-old infant. Which methods are appropriate to monitor the infant's growth pattern since birth? 1. Weight the infant twice and average together Correct Answer: 1,3,5 Rationale 1: In order to determine the infant's growth pattern the nurse will obtain two weights and average them together, measure the infant's head circumference, and obtain the infant's length, not height. After the measurements have been obtained the nurse will plot the measurements on the appropriate growth chart and monitor the infant's growth pattern. Body mass index is not determined during infancy. Which would the nurse anticipate when assessing a toddlerWhich should the nurse anticipate when assessing a toddler-age client's respirations? Respirations for the toddler-age client continue to be abdominal during the toddler-age years. Respirations are normal; therefore, the nurse does not anticipate tachypnea or dyspnea.
Which communication behavior would the nurse expect when assessing an 18 month old toddler quizlet?What communication behavior should the nurse expect when assessing the 18-month-old toddler? A vocabulary consisting of 8 to 10 words with telegraphic speech is expected of an 18-month-old toddler.
What would the nurse state is true about a toddlers sleep?What would the nurse state is true about a toddler's sleep? Total sleep averages 12 hours a day. In the awake period, a toddler exhibits sleepwalking. A toddler normally takes several naps during the day.
Which age range does the nurse know is classified as the toddler years?Toddlers (1-2 years of age)
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Which would the nurse anticipate when assessing a toddler age clients respirations quizlet?
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