2 - Physical Assessment Findings

Question 1

It is best to perform exams in _____ environments.

Answer 1

nonthreatening

Question 2

T/F: Take time to play and develop rapport prior to beginning an exam.

Answer 2

True

Question 3

T/F: Exam don’t need to be altered to accommodate developmental needs.

Answer 3

False ALTER exams to accommodate developmental needs

Question 4

What are things to observe for to determine the child’s readiness to cooperate?

Answer 4

• interacting with nurse - making eye contact - permitting physical touch - willing sitting on exam table

Question 5

If the child is uncooperative, what can be done?

Answer 5

• assess reasons - be firm and direct about expected behavior - complete the assessment quickly - use a calm voice

Question 6

T/F: Do not involve family members in exams.

Answer 6

False Involve children AND family members in exam

Question 7

Praise children for ____ during exams.

Answer 7

cooperation

Question 8

List some nursing considerations for physical assessments:

Answer 8

• keep room warm and well lit - keep medical equipment out of sight - provide privacy, include caregiver if needed - explain each step of the exam to the child - examine the child in a secure, comfy position - exam child in an organized sequence - encourage questions

Question 9

Recommended routes of taking temp for birth to 1 year?

Answer 9

Axillary or rectal (rectal if exact measurement is needed)

Question 10

Recommended routes of taking temp for 3 to 5 years?

Answer 10

Axillary, Tympanic, Oral, Rectal

Question 11

Recommended routes of taking temp for 7 to 13 years?

Answer 11

Oral, Axillary, Tympanic, Oral (This is how it’s listed in ATI on p. 9, but it may be a misprint…2 orals? maybe rectal instead)

Question 12

Expected temp for 3 mo & 6 mo:

Answer 12

37.5

Question 13

Expected temp for 1 year:

Answer 13

37.7

Question 14

Expected temp for 3 years:

Answer 14

37.2

Question 15

Expected temp for 5 years:

Answer 15

37.0

Question 16

Expected temp for 7 years:

Answer 16

36.8

Question 17

Expected temp for 9 and 11 years:

Answer 17

36.7

Question 18

Expected temp for 13 years:

Answer 18

36.6

Question 19

Pulse rate newborn:

Answer 19

80 - 180/min

Question 20

Pulse rate 1 week to 3 months:

Answer 20

80 - 220/min

Question 21

Pulse rate 3 month to 2 years:

Answer 21

70 - 150/min

Question 22

Pulse rate 2 to 10 years:

Answer 22

60 - 110/min

Question 23

Pulse rate 10 years and older:

Answer 23

50 - 90/min

Question 24

RR newborn to 1 year:

Answer 24

30 - 35/min

Question 25

RR 1 to 2 years:

Answer 25

25 - 30/min

Question 26

RR 2 to 6 years:

Answer 26

21 - 25/min

Question 27

RR 6 to 12 years:

Answer 27

19 - 21/min

Question 28

RR 12 years and older:

Answer 28

16 - 19/min

Question 29

What influences blood pressure?

Answer 29

- age - height - gender

Question 30

Infant systolic? Diastolic?

Answer 30

65 - 80 40 - 50

Question 31

Blood pressure by age...

Answer 31

Refer to chart on p. 10 of ATI book

Question 32

Physical Assessment: General Appearance...what do you look for?

Answer 32

- Undistressed - Clean and well-kept - Muscle tone (hold head up after 4 mo) - No body odor - Eye contact (except infants) - Follows simple commands - Uses speech, language, and motor skills spontaneously - Growth

Question 33

Physical Assessment: Skin...what do you look for?

Answer 33

- color appropriate for ethnicity - temp warm or slightly cool - turgor...brisk elasticity - texture smooth and dry, not oily - no lesions - skin folds symmetric

Question 34

Physical Assessment: Hair and scalp...what do you look for?

Answer 34

- hair evenly distributed, smooth, and strong - assess for secondary hair growth in adolescence - scalp clean and no scaliness, infestations, and trauma

Question 35

Hair that is stringy, dull, brittle, or dry may indicate what?

Answer 35

Nutritional deficiencies

Question 36

Physical Assessment: Nails...what do you look for?

Answer 36

- pink nail bed, white at tips - smooth and firm (infant nails slightly flexible) - no clubbing

Question 37

Physical Assessment: Lymph nodes...what do you look for?

Answer 37

- nonpalpable \*\* Lymph nodes that are small, palpable, nontender, and mobile may be an expected finding in children

Question 38

Physical Assessment: Head...what do you look for?

Answer 38

- shape symmetric - fontanels flat

Question 39

Posterior fontanel closes by ___ weeks. Anterior fontanel closes by ___ weeks.

Answer 39

Posterior: 8 weeks Anterior: 18 weeks

Question 40

Physical Assessment: Face...what do you look for?

Answer 40

- symmetric appearance and movement - proportional features

Question 41

Physical Assessment: Neck...what do you look for?

Answer 41

- short in infants - no palpable masses - midline trachea - full range of motion

Question 42

Where do you check skin turgor in babies/children?

Answer 42

inner thigh or abdomen

Question 43

Physical Assessment: Eyes...what do you look for?

Answer 43

- visual acuity (difficult in children under 3 years) - color vision - correctly identify shapes, symbols, or numbers - peripheral visual fields (up 50, down 70, nasally 60, temporally 90) - extraocular movements may not be symmetric in newborns - eyebrows symmetric and evenly distributed from inner to outer canthus - eyelids open and close completely - eyelashes curve outward, evenly distributed, no inflammation around hair follicles - conjunctiva (palpebral pink, bulbar transparent) - lacrimal apparatus w/o excessive tearing, redness, or discharge - sclera white - corneas clear - pupils round, equal, reactive to light, accommodating - irises round; permanent color around 6 - 12 mo - red reflex present in infants - arteries, veins, optic discs, and maculas may be visualized in older children and adolescents

Question 44

How can visual acuity be assessed in infants?

Answer 44

Hold object in front of eyes checking to see if infant is able to fix on the object and follow it.

Question 45

For children unable to read letters and numbers, which vision charts are used?

Answer 45

- tumbling E - HOTV test

Question 46

What charts are used to test vision in older children?

Answer 46

- Snellen chart - symbol chart

Question 47

How is color vision assessed?

Answer 47

- Ishihara color test - Hardy-Rand-Rittler test