Nokea
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.
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Which explains why correcting strabismus in young children is important?
- A. Color vision may be lost.
- B. Amblyopia, a type of blindness, may result.
- C. Epicanthal folds may develop in the affected eye.
- D. Corneal light reflexes may fall symmetrically within each pupil.
Correct Answer: B
Rationale: By the age of 3 to 4 months, infants are able to fixate on one visual field with both eyes simultaneously. In strabismus, or cross-eye, one eye deviates from the point of fixation. If misalignment is constant, the weak eye becomes lazy, and the brain eventually suppresses the image produced from that eye. If strabismus is not detected and corrected by age 4 to 6 years, blindness from disuse, known as amblyopia, may occur. Color vision is not the only concern. Epicanthal folds are not related to amblyopia. In children with strabismus, the corneal light reflex will not be symmetric for each eye.
With the National Center for Health Statistics criteria, which body mass index (BMI)-for-age percentiles should indicate the patient is at risk for being overweight?
- A. 10th percentile
- B. 75th percentile
- C. 85th percentile
- D. 95th percentile
Correct Answer: C
Rationale: Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits.
What is the earliest age at which a satisfactory radial pulse can be taken in children?
- A. 1 year
- B. 2 years
- C. 3 years
- D. 6 years
Correct Answer: B
Rationale: Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.
The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful?
- A. Recommend that the child keep a diary.
- B. Provide supplies for the child to draw a picture.
- C. Suggest that the parent read fairy tales to the child.
- D. Ask the parent if the child is always uncommunicative.
Correct Answer: B
Rationale: Drawing is one of the most valuable forms of communication. Childrens drawings tell a great deal about them because they are projections of the childrens inner self. A diary should be difficult for a 6-year-old child, who is most likely learning to read. The parent reading fairy tales to the child is a passive activity involving the parent and child; it should not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not always uncommunicative.
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.