Mod 1 Evolve Practice Qs Show Ch. 33 - Physical Assessment of Children 1. A 4-month-old is sleeping during her well infant checkup. Which assessment should the nurse do first? -Auscultation 2. The nurse is assessing a 6-month-old infant who smiles, coos, & has a strong head lag. What assessment should the nurse make about this infant’s development? -A developmental/neurologic follow-up evaluation is needed. 3. The nurse is performing a well-child examination. Which is the most accurate method of determining the length of a child less than 24 months of age? -Measure the child recumbent in the supine position. 4. The RN is performing a basic neuro assessment of a 6-mo.-old. How can nurse accurately assess CN V? -Watch how the baby sucks on his pacifier. 5. The nurse is assessing a preschooler’s chest as part of a well-child exam. What normal findings would the nurse expect to document? -Movement of the chest wall to be symmetric bilaterally & coordinated w/ breathing. 6. Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation & promote relaxation? -Have the child “help” with palpation by placing his or her hand over the palpating hand. 7. When the nurse lifts the skin on the abdomen and releases it quickly to check skin turgor, the tissue remains suspended for a few seconds, then slowly falls back on the abdomen. Which evaluation can the nurse correctly determine from the findings? -The child is dehydrated. 8. The nurse is doing a neuro assessment on a child whose level of consciousness has been variable since sustaining a cervical neck injury 12 hrs ago. Which is the most essential part in this assessment? -Checking the reactivity of pupils. 9. The nurse is preparing to assess lung sounds of a 3-mo.-old sleeping infant who is being held on her belly by her mom against the upper chest. Which techniques should the RN use to obtain an accurate assessment? -Identify the hyperresonance heard as normal because of the thin chest wall. -Assess the lungs from the apex to the base bilaterally. -Auscultate the lung sounds through her back. 10. The nurse is performing a well-child exam. During an otoscopic examination on an infant, in which direction should the nurse gently pull the pinna? -Down and back 11. The nurse needs to check the blood pressure of a small child with no suspected cardiac problem. Of the cuffs available, one is too large and one is too small. What nursing action is best? -Wait to check the blood pressure until a proper cuff can be located 12. The nurse is ready to begin a physical exam of an 8-month-old infant who is sitting contentedly on her mother’s lap, chewing on a toy. Which assessment should the nurse do first? -Heart and lungs 13. The nurse is doing a neuro assessment on a 2-month-old infant after a car accident. Moro, tonic neck, & withdrawal reflexes are present. What evaluation of these findings by the nurse is correct? -The infant’s neurologic status is appropriate. 14. The anterior fontanel appears slightly bulging when a 4 mo. old cries. What action by the nurse is indicated? -Document the findings Whether the setting is a hospital or other healthcare facility, it is important to gather information regarding the child’s history and current status.
Collecting Subjective DataInformation spoken by the child or family is called subjective data. Conducting the Client InterviewMost subjective data are collected through interviewing the family caregiver and the child.
Interviewing Family CaregiversThe family caregiver provides most of the information needed in caring for the child, especially the infant or toddler.
Interviewing the ChildIt is important that the preschool child and the older child be included in the interview.
Interviewing the AdolescentAdolescents can provide information about themselves.
Obtaining a Client HistoryWhen a child is brought to any health care setting, it is important to gather information regarding the child’s current condition, as well as medical history.
Collecting Objective DataObjective data in nursing is part of the health assessment that involves the collection of information through observations. The collection of objective data includes the nurse doing a baseline measurement of the child’s height, weight, blood pressure, temperature, pulse, and respiration. General StatusThe nurse uses knowledge of normal growth and development to note if the child appears to fit the characteristics of the stated age.
Measuring Height and WeightThe child’s height and weight are helpful indicators of growth and development.
Measuring Head CircumferenceThe head circumference us measured routinely in children to the age 2 or 3 years or in any child with a neurologic concern. Measuring head circumference using a tape measure. Image via: YouTube.com
Vital SignsVital signs, including temperature, pulse, respirations, and blood pressure, are taken at each visit and compared with the normal values for children at the same age. Temperature
Pulse
Respirations
Blood pressure
Physical ExaminationData are also collected by examining the body systems of the child. Head and NeckSymmetry or a balance is noted in the features of the face and in the head.
Chest and LungsChest measurements are done on infants and children to determine normal growth rate.
HeartIn some infants and children, a pulsation can be seen in the chest that indicates the heart beat, which is called the point of maximum impulse.
AbdomenThe abdomen may protrude slightly in infants and small children.
Genitalia and RectumWhen inspecting the genitalia and rectum, it is important to respect the child’s privacy and take into account the child’s age and stage of growth and development.
Back and ExtremitiesThe back and extremities should also be assessed for abnormalities.
NeurologicAssessing the neurologic status of the infant and child is the most complex aspect of the physical exam.
What should the nurse assess last when examining a 5 year old?Which assessment should the nurse perform last when examining a 5-year-old child? Rationale: Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination.
What is the proper order of assessment for a child?When performing the physical assessment, the nurse uses the four basic techniques of inspection, palpation, percussion, and auscultation, generally in that order. During the abdominal examination, the sequence is altered; inspection is performed first, and then auscultation, percussion, and palpation.
What is the correct order for physical assessment?Order of physical assessment: Inspect, palpate, percuss, auscultate. EXCEPT for assessing the abdomen: Inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).
What are the 4 types of physical assessment?WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.
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