Nokea
An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?
- 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 as it is used.
Correct Answer: C
Rationale: School-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 so that the child can then observe during the procedure. The nurse should respond positively for 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 in asking how the blood pressure apparatus works, just requesting clarification of what will occur.
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The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action?
- A. Ask the parent when the neck was injured.
- B. Refer for immediate medical evaluation.
- C. Continue assessment to determine the cause of the neck pain.
- D. Record head lag on the assessment record and continue the assessment of the child.
Correct Answer: B
Rationale: Hyperextension of the childs head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag.
The nurse is preparing to perform a physical assessment on a 10-year-old girl. The nurse gives her the option of her mother staying in the room or leaving. This action should be considered which?
- A. Appropriate because of childs age
- B. Appropriate, but the mother may be uncomfortable
- C. Inappropriate because of childs age
- D. Inappropriate because child is same sex as mother
Correct Answer: A
Rationale: It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination.
What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
- A. Rinne test
- B. Weber test
- C. Pure tone audiometry
- D. Eliciting the startle reflex
Correct Answer: C
Rationale: Pure tone audiometry uses an audiometer that produces sounds at different volumes and pitches in the childs ears. The child is asked to respond in some way when the tone is heard in the earphone. The Rinne and Weber tests measure bone conduction of sound. Eliciting the startle reflex may be useful in infants.
When doing a nutritional assessment on a Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet is which?
- A. Lacking in protein
- B. Indicating they live in poverty
- C. Providing sufficient amino acids
- D. Needing enrichment with meat and milk
Correct Answer: C
Rationale: A diet that contains vegetables, legumes, and starches may provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. Combinations of foods contain the essential amino acids necessary for growth. Many cultures use diets that contain this combination of foods. It is not indicative of poverty. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.
Where is the best place to observe for the presence of petechiae in dark-skinned individuals?
- A. Face
- B. Buttocks
- C. Oral mucosa
- D. Palms and soles
Correct Answer: C
Rationale: Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark-skinned individuals unless they are in the mouth or conjunctiva.