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The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first?a. Introduce him- or herself.b. Make the family comfortable.c. Explain the purpose of the interview.d. Give an assurance of privacy.

ANS: AThe first thing that nurses must do is introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. Next, the purpose of the interview and the nurse’s role should be clarified. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality


What approach is most likely to encourage parents to talk about their feelings related to their child’s illness?a. Being sympatheticb. Using direct questionsc. Using open-ended questionsd. Avoiding periods of silence

ANS: CClosed-ended questions should be avoided when attempting to elicit parents’ feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is defined as having feelings or emotions in common with another person, rather than understanding those feelings (which is called empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may only obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows two or more people to share feelings and absorb one another’s emotions in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions


What is the single most important factor to consider when communicating with children?a. The child’s physical conditionb. The presence or absence of the child’s parentc. The child’s developmental leveld. The child’s non-verbal behaviours

ANS: CThe nurse must be aware of the child’s developmental stage to engage in effective communication. An understanding of the typical characteristics of these stages provides the nurse with a framework to facilitate social communication. The use of both verbal and non-verbal communication should be appropriate to the developmental level. Although the child’s physical condition is a consideration, developmental level is much more important. The parents’ presence is important when communicating with young children, but it may be detrimental when speaking with adolescents. Non-verbal behaviours vary in importance based on the child’s developmental level.


What is an important consideration for the nurse who is communicating with a very young child?a. Speak loudly, clearly, and directly.b. Use transition objects, such as a doll.c. Disguise one’s own feelings, attitudes, and anxiety.d. Initiate contact with the child when his or her parent is not present.

ANS: BUsing a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse), facilitating communication. Speaking loudly, clearly, and directly tends to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception lead to a lack of trust. Whenever possible, a parent should be present for interactions with young children.


When introducing hospital equipment to a preschooler who seems afraid, which of the following principles should the nurse keep in mind?a. The child may think the equipment is alive.b. The child is too young to understand what the equipment does.c. Explaining the equipment will only increase the child’s fear.d. One brief explanation is enough to reduce the child’s fear.

ANS: AYoung children attribute human characteristics to inanimate objects. They often fear that an object may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. The nurse should give the child simple, concrete explanations about what the equipment does and how it will feel to help alleviate the child’s fear. Preschoolers will need repeated explanations for reassurance.


Which age group is most concerned with body integrity?a. Toddlersb. Preschoolersc. School-age childrend. Adolescents

ANS: CSchool-age children have heightened concerns about body integrity. They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggests injury. Body integrity is not as important to children in the toddler, preschooler, and adolescent age groups


An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate act for the nurse to take?a. Ask her why she wants to know.b. Determine why she is so anxious.c. Explain in simple terms how it works.d. Tell her she will see how it works when it is used.

ANS: CSchool-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. The nurse should respond positively to requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification about what will be occurring. The nurse must explain how the blood pressure cuff works ahead of time so the child can then quietly observe during the procedure.


What is the most important thing for a nurse to say when interviewing an adolescent?a. Focus the discussion on the peer group.b. Allow for an opportunity to express feelings.c. Emphasize that confidentiality will always be maintained.d. Use the same type of language as the adolescent.

ANS: BAdolescents, like all children, need an opportunity to express their feelings. Often they will inject feelings into their words. The nurse must be alert to both the words and feelings expressed. Although their peer group is important to those in this age group, the focus of the interview should be on the individual adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with the adolescent. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently


The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique is most helpful in improving communication?a. Suggest that the child keep a diary.b. Suggest that the parent read fairytales to the child.c. Ask the parent if the child is always uncommunicative.d. Ask the child to draw a picture.

ANS: DDrawing is one of the most valuable forms of communication. Children’s drawings tell a great deal about them because they are projections of the child’s inner self. It would be difficult for a 6-year-old child to keep a diary, since the child is most likely just learning to read. Reading fairytales to the child is a passive activity involving the parent and child, and would not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not necessarily uncommunicative.


A nurse is taking the health history of an adolescent. Which statement best describes how to determine the chief complaint?a. Ask for a detailed listing of symptoms.b. Ask the adolescent, “Why did you come here today?”c. Use what adolescent says to determine, in correct medical terminology, what the problem is.d. Interview the parent away from adolescent to determine chief complaint.

ANS: BThe chief complaint is the specific reason for the adolescent’s visit to the clinic, office, or hospital. The adolescent is the focus of the history, so this is an appropriate way to determine the chief complaint. A list of symptoms will make it difficult to determine the chief complaint. The nurse should prompt the adolescent to state which symptom caused him to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention, not the parent.


Where in the health history should the nurse describe all the details related to the chief complaint?a. Past historyb. Chief complaintc. Present illnessd. Review of systems

ANS: CThe history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, at different intervals, and in the present. Past history refers to information that relates to previous aspects of the child’s health, not to the current problem. The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital; it does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.


The nurse is interviewing the mother of an infant. She reports, “I had a difficult delivery, and my baby was born prematurely.” This information should be recorded under which heading?a. Birth historyb. Present illnessc. Chief complaintd. Review of systems

ANS: AThe birth history is information that relates to previous aspects of the child’s health, not to the current problem. The mother’s difficult delivery and prematurity are important parts of an infant’s past history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness. The chief complaint is the specific reason for the child’s visit to the clinic, office, or hospital, and would not include birth information. The review of systems is a specific review of each body system, and does not include premature birth. Sequelae such as pulmonary dysfunction would be included.


When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones, such as the age when he started walking without assistance. How should milestones be considered?a. They are unnecessary because the child is age 3 years.b. They are an important part of the family history.c. They are an important part of the child’s past growth and development.d. They are an important part of the child’s review of systems.

ANS: CIt is important for the nurse to obtain information about the attainment of developmental milestones because they provide data about the child’s growth that should be included in the history. Developmental milestones provide important information about the child’s physical, social, and neurological health. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones.


A nurse is taking the sexual history of an adolescent girl. Which is the best way to determine whether she is sexually active?a. Ask, “Are you sexually active?”b. Ask, “Are you having sex with anyone?”c. Ask, “Are you having sex with a boyfriend?”d. Ask both the girl and her parent if she is sexually active.

ANS: BAsking the adolescent girl if she is having sex with anyone is a direct question that is easy to understand. The phrase sexually active is broadly defined and may not give specific enough information for the nurse to provide the necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend, because homosexual experimentation may occur. Questioning about sexual activity should occur when the adolescent is alone.


A nurse knows that the patient is experiencing information overload when she observes that the patient is doing one of the following?a. Maintains eye contactb. Plays with hairc. Has fixed, narrowed eyesd. Remains focused on the topic of discussion

ANS: BNervous habits, such as playing with one’s hair, are a sign that the patient has information overload. Other signs include avoiding eye contact, wide eyes, and attempting to change the topic of discussion


Which parameter correlates best with measurements of the body’s total protein stores?a. Heightb. Weightc. Skin-fold thicknessd. Upper arm circumference

ANS: DUpper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body’s major protein reserve and is considered an index of the body’s protein stores. Height is reflective of past nutritional status, and weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the body’s fat content


Which one of the following is an appropriate approach to performing a physical assessment on a toddler?a. Always proceed in a head-to-toe direction.b. Perform traumatic procedures first.c. Use minimum physical contact initially.d. Demonstrate use of equipment.

ANS: CParents can remove clothing, and the child can remain on the parent’s lap. The nurse should use minimum physical contact initially to gain the child’s cooperation. The head-to-toe assessment can be done in older children, but usually must be adapted for younger children. Traumatic procedures should always be performed last because they will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age group


According to the WHO Growth Reference Charts, which body mass index (BMI)-for-age percentile indicates a risk for being overweight?a. 10th percentileb. 25th percentilec. 90th percentiled. 95th percentile

ANS: CThe 2007 WHO Growth Reference Charts include data that reflect healthy growth and can be used to identify children who are at risk for obesity. Children who have BMI-for-age greater than or equal to the 90th percentile are at risk. Children in the 10th and 25th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight.


Which of the following statements describes the emerging illocutionary stage?a. The child is reflexive to stimuli.b. The child shows increasing purpose in action.c. The child communicates intentionally with signals and gestures.d. The child communicates intentionally with vocalizations and verbalizations.

ANS: CThe emerging illocutionary stage (8-9 to 12-15 months) is when the child communicates intentionally with signals and gestures. The child reflexive to stimuli and showing increasing purpose in action is in the perlocutionary stage. The child communicating intentionally with vocalizations and verbalizations is in the conventional illocutionary–emerging locutionary stage.


Which tool measures body fat most accurately?a. Stadiometerb. Calipersc. Cloth tape measured. Paper or metal tape measure

ANS: BCalipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.


By what age do the head and chest circumferences generally become equal?a. 1 monthb. 6 to 9 monthsc. 1 to 2 yearsd. 2.5 to 3 years

ANS: CHead circumference begins larger than chest circumference. Between the ages of 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference at 1 month and 6 to 9 months. Chest circumference is larger than head circumference at age 2.5 to 3 years.


What is the earliest age at which a satisfactory radial pulse can be taken in children?a. 1 yearb. 2 yearsc. 3 yearsd. 6 years

ANS: BSatisfactory radial pulses can be used in children older than 2 years. In infants and young children the apical pulse is more reliable. The radial pulse can be used for assessment at ages 3 and 6 years.


Where is the best place to observe for the presence of petechiae in dark-skinned individuals?a. Faceb. Buttocksc. Oral mucosad. Palms and soles

ANS: CPetechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.


When palpating a child’s cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. What is the best explanation for this finding?a. Some form of cancerb. Local scalp infection common in childrenc. Infection or inflammation distal to the sited. Infection or inflammation close to the site

ANS: DSmall, non-tender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes do not usually indicate cancer. A scalp infection usually does not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed.


The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child’s head (opisthotonos), with pain on flexion. What is the priority action?a. Refer for immediate medical evaluation.b. Continue assessment to determine cause of neck pain.c. Ask parent when neck was injured.d. Record “head lag” on assessment record and continue assessment of child.

ANS: AThese symptoms indicate meningeal irritation and the child needs immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag.


When teaching new parents about their infants’ anterior fontanel, the nurse tells them that it will close at which age?a. 2 monthsb. 2 to 4 monthsc. 6 to 8 monthsd. 12 to 18 months

ANS: DThe expected closure of the anterior fontanel occurs between 12 and 18 months; 2 through 8 months is too soon. If it closes at these earlier ages, the child should be referred for further evaluation.


During a funduscopic examination of a school-aged child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which of the following?a. A normal findingb. An abnormal finding; the child needs a referral to an ophthalmologistc. A sign of possible visual defect; the child needs vision screeningd. A sign of small hemorrhages, which usually resolve spontaneously

ANS: AA brilliant, uniform red reflex is an important normal and expected finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.


Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age?a. 1 monthb. 3 to 4 monthsc. 6 to 8 monthsd. 12 months

ANS: BBinocularity is usually achieved by ages 3 to 4 months. One month is too young for binocularity. If binocularity is not achieved by 6 months, the child must be observed for strabismus.


What is the most frequently used test for measuring visual acuity?a. Denver Eye Screening testb. Allen picture card testc. Ishihara vision testd. Snellen letter chart

ANS: DThe Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. Single cards (Denver—letter E; Allen—pictures) are used for children age 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for colour vision.


The nurse is testing an infant’s visual acuity. By what age should the infant be able to fix on and follow a target?a. 1 monthb. 1 to 2 monthsc. 3 to 4 monthsd. 6 months

ANS: CVisual fixation and following a target should be present by ages 3 to 4 months. Ages 1 to 2 months are too young for this developmental milestone. If the infant is not able to fix and follow by 6 months of age, further ophthalmologic evaluation is needed.