A nurse is performing a physical examination on a newborn. Which of the following assessments should she include? Show a) Rectal temperature, femoral pulse, head circumference The nurse is examining the testicles of a 6-year-old boy. How can the nurse prevent a retractile testis from slipping back up the inguinal canal? a) Ask the boy to stand. Ask the boy to sit cross-legged. For a 6-year-old boy, sitting cross-legged reduces the cremasteric reflex that retracts the testicles during palpation. Having a boy stand is best for an adolescent. Placing a finger over the inguinal canal or applying gentle pressure would be best for an infant. A child on a cardiac monitor has been transported from the emergency room to the intensive care unit. The nurse admits the child to the unit and begins collecting data on the child. Which of the following nursing interventions would the nurse do first? a)
Change the probe on the pulse oximeter. Verify that the alarms on the monitor are still properly set. At the beginning of each shift and after transport of the patient, the nurse must check that alarms are accurately set and have not been inadvertently changed. This is true for all types of monitors. The neurological status will most likely be checked, as well as the apical pulse, but they are not priorities. The probe on the pulse oximeter is changed if needed, but not routinely and not as a priority. The nurse is conducting a physical examination of a 5-year-old girl. The nurse asks the girl to stand still with her eyes closed and arms down by her side. The girl immediately begins to lean. What does this tell the nurse? a) The child has a negative Romberg test; no further testing is necessary. The child warrants further testing for cerebellar dysfunction. This indicates a positive Romberg test which warrants further testing for possible cerebellar dysfunction. The nurse is caring for a child who is on a cardiac monitor. Which of the following nursing actions would be the most important action for the nurse? a) Check to be sure that the electrodes are secure when the alarm sounds. Confirm the alarms are set with maximum and minimum settings. Cardiac monitors are used to detect changes in cardiac function. The highest priority would be to ensure the alarms are set with maximum and minimum settings and that the alarm is turned on. Many of these monitors have a visual display of the cardiac actions. Electrodes must be placed properly to obtain accurate readings of the cardiac system. The skin is cleaned to remove dirt, lotions, and powder before the electrodes are applied. The electrode sites must be checked every two hours to detect any skin redness or irritation and to determine that the electrodes are secure. A nurse is conducting a physical examination of an uncooperative preschooler. In order to encourage deep breathing during lung auscultation what could the nurse say? a) "Do you think you can blow out my light bulb on this pen?" "Do you think you can blow out my light bulb on this pen?" Preschoolers like to play games. To encourage deep breathing, the nurse should elicit the child's cooperation by engaging the child in a game to blow out the light bulb on the penlight. Telling the child that he or she may not leave or must breathe deeply would not engage the child. Asking whether the child would allow his or her caregiver to listen would most likely elicit a no. When assessing symptoms such as rashes, pain, or lesions, what would be included in the location factor of the symptom? a) quality localized or generalized When assessing symptoms such as pain, rashes, or lesions, the location must be assessed for local or generalized. Pain should also be assessed for deep, superficial, or radiating. The other choices describe the quality and quantity of the symptom. When obtaining a child's health history the child's biological data is assessed. What is the next thing to assess in the child's history? a) The chief complaint of the child The chief complaint of the child The next step in the health assessment is the reason for seeking treatment. Remember to include the child's reason because it may be different from that of the parent or caretaker The nurse is beginning the examination of a 4-month-old infant. She takes the infant from the mother's arms to do the exam. Where should the nurse place the infant for the exam? a) In the crib on the infant's back In the crib facing the mom When performing an exam on an infant, the nurse should place the infant in a position so that the parent is in view at all times. This is supportive and comforting to the infant. The other choices do not keep the parent in view All infants should have their head circumference measured at health-assessment visits. This measurement is made from a) the middle of the forehead through the parietal prominences. just above the eyebrows through the prominent part of the occiput. Measuring heads consistently from above the eyebrows to the occiput allows measurements at different visits to be compared. The nurse examines a 3-year-old girl in a health maintenance setting. What is the first question the nurse would ask her mother to obtain a health history? a) "Has your daughter been ill in the past?" "Do you have any concerns about your daughter?" Beginning a health interview with an open-ended question about a chief concern opens up many topics for discussion. The nurse is visualizing the ear canal and tympanic membrane of a 14-month-old boy. Which finding would warrant further investigation? a) A pearly pink membrane A bubble behind the tympanic membrane A bubble behind the tympanic membrane is not a normal finding and indicates a need for further investigation. The other findings are within normal limits. A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first? a) History of past illnesses Details about the fever Health interviews typically begin with a history of the chief complaint, because this is what people want to talk about first and represents a primary health problem. Where is the point of maximal impulse (PMI) found in a 5-year-old girl? a) The fourth intercostal space. The fourth intercostal space. The area of most intense cardiac pulsation, or point of maximal impulse (PMI), varies with age. In children younger than 7 it occurs at the fourth intercostal space. When doing a health assessment on a child, the nurse should include a physical assessment. What is the most important thing to assess first when performing the physical assessment? a) Blood pressure Respirations The assessment of respirations should always be done first. Completing other parts of the physical assessment could influence the count of respirations. A 4-year-old girl reports having ear pain. To examine the child's ear, how should the nurse proceed? a) Grasp the pinna and pull up and back. Grasp the pinna and pull up and back. The ear is examined in a child younger than 3 years of age by pulling the pinna down and back. In a child over 3 years old, the ear is examined by pulling the pinna up and back. These maneuvers straighten the ear canal so that the tympanic membrane can be visualized. The nurse is weighing an 18-month-old infant who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child? a) The nurse should lay the infant on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight. The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The toddler who is able to sit can be weighed while sitting. Keep a hand within 1 inch of the child at all times to be ready to protect the child from injury. Which assessment would you expect to introduce for the first time in the physical examination of a 3-year-old child? a) Snellen vision testing Blood-pressure recording Assessing blood pressure is generally introduced at preschool age. The preschool E-chart is used for vision screening at this age. The nurse is auscultating the heart of a 6-month-old. Which finding would warrant further investigation? a) S1 varies in intensity. S1 varies in intensity. The S1 should not vary in intensity at a particular point. If it does, this may indicate a cardiac arrhythmia, and the child should be referred for further evaluation. A split S2 at the apex occurs in many infants and young children. The other findings are within the normal range for a child of 6 months. The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately? a) Tympany over the abdomen Visible peristaltic waves Visible peristaltic waves are abnormal and require further evaluation. The other findings are considered normal for the child's age. What is typical of a grade II heart murmur? a) The murmur is loud with an associated thrill. The murmur is soft but easily heard. When assessing heart murmurs, a grading scale is used to describe the sound of the murmur. A grade II heart murmur is usually soft and it is easily auscultated. The nurse is gathering data from the caregiver of a 3-year-old boy. While in the waiting room, the nurse heard the caregiver say the boy feels nauseated. In interviewing the child's caregiver, what would be the most appropriate initial question for the nurse to ask? a) "What caused you to decide to bring your son to the clinic today?" "What caused you to decide to bring your son to the clinic today?" To best care for the child, it is important to get the most complete explanation of what brought the child to the health care setting. Repeating the caregiver's statement regarding the child's chief complaint would be helpful in clarifying that the nurse has correctly heard what the caregiver has said. The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? a) Purpura Salmon nevus A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin. The nurse is doing an assessment of a 10-year-old girl. She whispers the girl's name from behind the girl. Which cranial nerve is the nurse assessing for? a) VIII VIII Testing a child's hearing by observing a response to a whisper without a visual clue, assesses cranial nerve VIII, the acoustic nerve. Nerve V is the trigeminal, nerve IV is the trochlear, and nerve III is the oculomotor, none of which are involved in hearing. The nursing students are learning how to perform a health assessment on a pediatric patient. The nursing instructor identifies a need for further teaching when a student states: a) "I should establish good rapport with the child's parents before beginning an assessment on a child." "I should take blood pressure on a child beginning at age 2 years." When performing assessments, the nurse does not usually take blood pressure on children younger than 3 years. The nurse should always establish good rapport with the child's parents. The nurse would use an electronic thermometer to take a temperature on a child who is 3 years. A nurse is performing a physical examination on a newborn. Which assessment should she include? a) Axillary temperature, femoral pulse, head circumference
Axillary temperature, femoral pulse, head circumference When examining newborns, take axillary or temporal temperatures to prevent rupture of rectal mucosa. Be certain to take femoral pulses in newborns to rule out coarctation of the aorta. Include newborn reflexes, head circumference, and an assessment of gestational age as routine parts of the examination. Taking blood pressure is not necessary because this value is unreliable in newborns.
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do? a) Take a radial pulse. Take the apical pulse. Taking the apical pulse with a pediatric stethoscope and counting the rate for a full minute is the most accurate way to obtain the heart rate on an infant. The radial pulse should only be used in older children over the age of 10 as it is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lie close to the skin surface and are easily obliterated. The nurse is taking an apical pulse on an infant. The nurse should place the stethoscope at which of the following sites? a) Below the ribs about one half of an inch Between the sternum and the left nipple When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum. The nurse is conducting the Denver Articulation Screening with a 5-year-old girl to assess her speech. Which of the following should the nurse do while conducting this exam? a)
Have the child read each of the 22 words from a sheet of paper Convey the impression that there are no right or wrong answers The Denver Articulation Screening is designed to detect significant developmental delays as well as normal variations in the acquisition of speech sounds. Because it is a standardized test, its directions must be followed precisely, not modified according to the nurse's own discretion. Before the test, explain the child will need to repeat the words she hears you speak. Give enough examples you are certain she understands what she is to do: "When I say 'boat,' then you say 'boat.'" When you are certain the child understands the directions, say each of the 22 words shown on the Denver Articulation Screening form; do not have the child read the words from a sheet of paper. Convey the impression that there are no right or wrong answers. Give the child approval for responding and following directions correctly, no matter how inaccurately the child repeats the word; the nurse should not explain which words the child missed and why. The emergency department nurse is caring for a child who is showing signs of anaphylaxis. The nurse evaluates how comprehensive the history of the child should be and determines that which action takes priority? a) Stabilizing the child's physical status Stabilizing the child's physical status The nurse knows that some of the history must be delayed until after the child is stabilized. After the child is stabilized the nurse can take a detailed history. The child who has received routine health care and presents with a mild illness would need only a problem-focused history. The nurse should be sensitive to repetitive interviews in hospital situations but should not assume that the child's history can be obtained from other providers. A complete and detailed history would be in order if physicians rarely see the child or if the child is critically ill. The mother of 2-year-old triplets is anxious and worried because one of the children does not seem to be at the same developmental level as her siblings. Which finding might indicate a need for further diagnostic testing to rule out intellectual disability in this child? a) She speaks loudly when asked a question. The tops of her ears are below the corners of her eyes. The alignment of the ears is noted by drawing an imaginary line from the outside corner of the eye to the prominent part of the child's skull; the top of the ear, known as the pinna, should cross this line. Ears that are set low often indicate intellectual disability. Flaring of the nostrils might indicate respiratory distress and should be reported immediately. A child who speaks loudly, responds inappropriately, or does not speak clearly may have hearing difficulties that should be explored. It would be normal for the fontanels to be closed by this age. A child who is developing normally should be able to control her head's range of motion; any stiffness in the neck should be reported immediately. Where would the S2 "dub" sound be the loudest? a) The fifth intercostal space The second intercostal space The aortic area is auscultated in the second intercostal space. Here the S2 sound is louder than S1 and is a "dub" sound. The nurse is examining the genitals of a healthy newborn girl. The nurse should observe which normal finding? a) Swollen labia minora Swollen labia minora The newborn's labia minora is typically swollen from the effects of maternal estrogen. The minora will decrease in size and be hidden by the labia majora within the first weeks. Lesions on the external genitalia are indicative of sexually transmitted infection. Labial adhesions are not a normal finding for a healthy newborn. Swollen labia majora is not a normal finding. When testing the deep tendon reflexes of a child, a four-point grading scale is used. What would a 1+ result mean for a reflex tested? a) The reflex is absent. The reflex is diminished. On the four-point grading scale used in assessing deep tendon reflexes, 1+ indicates a diminished response. With 2+ as average, a grade of 3+ is brisker than average and 4+ is hyperactive. The reflex is absent at a grade of 0. (less) What is the first step in a physical assessment?Inspection. In medical terms, “inspection” means to look at the person or body part. It is the first step in a physical exam.
What is the most important thing to assess first when performing a physical assessment on a child?What is the most important thing to assess first when performing the physical assessment? The assessment of respirations should always be done first.
What are the steps to a physical assessment?The components of a physical exam include:. Inspection. Your examiner will look at, or "inspect" specific areas of your body for normal color, shape and consistency. ... . Palpation. ... . Percussion. ... . Auscultation. ... . The Neurologic Examination:. How do you physically assess a child?The infant or child's face should be symmetrical; observe for nutritional status, hygiene, mental alertness, and body posture and movements; examine the skin for color, lesions, bruises, scars, and birthmarks; observe hair texture, thickness, and distribution. Noting psychological status and behavior.
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When doing a health assessment on a child the nurse should include a physical assessment What should the nurse assess first when performing the physical assessment?
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