Nokea
Because children younger than 5 years are egocentric, the nurse should do which when communicating with them?
- A. Focus communication on the child.
- B. Use easy analogies when possible.
- C. Explain experiences of others to the child.
- D. Assure the child that communication is private.
Correct Answer: A
Rationale: Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding.
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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.
The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined?
- A. Request a detailed listing of symptoms.
- B. Ask the adolescent, Why did you come here today?
- C. Interview the parent away from the adolescent to determine the chief complaint.
- D. Use what the adolescent says to determine, in correct medical terminology, what the problem is.
Correct Answer: B
Rationale: The chief complaint is the specific reason for the childs visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. Requesting a detailed list of symptoms makes it difficult to determine the chief complaint. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention 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.
Rectal temperatures are indicated in which situation?
- A. In the newborn period
- B. Whenever accuracy is essential
- C. Rectal temperatures are never indicated
- D. When rapid temperature changes are occurring
Correct Answer: B
Rationale: Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.
The nurse is testing an infants visual acuity. By which age should the infant be able to fix on and follow a target?
- A. 1 month
- B. 1 to 2 months
- C. 3 to 4 months
- D. 6 months
Correct Answer: C
Rationale: Visual fixation and ability to follow a target should be present by ages 3 to 4 months. One to 2 months is too young for this developmental milestone. If an infant is not able to fix and follow by 6 months, further ophthalmologic evaluation is needed.
Which data should be included in a health history?
- A. Review of systems
- B. Physical assessment
- C. Growth measurements
- D. Record of vital signs
Correct Answer: A
Rationale: A review of systems is done to elicit information concerning any potential health problems. This further guides the interview process. Physical assessment, growth measurements, and a record of vital signs are components of the physical examination.