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The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first?
- A. Introduce him- or herself.
- B. Make the family comfortable.
- C. Give assurance of privacy.
- D. Explain the purpose of the interview.
Correct Answer: A
Rationale: The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurses role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also 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 the confidentiality.
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During a routine health assessment, the nurse notes that an 8-month-old infant has a significant head lag. Which is the most appropriate action?
- A. Recheck head control at next visit.
- B. Teach the parents appropriate exercises.
- C. Schedule the child for further evaluation.
- D. Refer the child for further evaluation if the anterior fontanel is still open.
Correct Answer: C
Rationale: Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Head control is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.
During an otoscopic examination on an infant, in which direction is the pinna pulled?
- A. Up and back
- B. Up and forward
- C. Down and back
- D. Down and forward
Correct Answer: C
Rationale: In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 oclock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 oclock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal.
The nurse is preparing to assess a 10-month-old infant. He is sitting on his fathers lap and appears to be afraid of the nurse and of what might happen next. Which initial actions by the nurse should be most appropriate?
- A. Initiate a game of peek-a-boo.
- B. Ask the infants father to place the infant on the examination table.
- C. Talk softly to the infant while taking him from his father.
- D. Undress the infant while he is still sitting on his fathers lap.
Correct Answer: A
Rationale: Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done with the child on the fathers lap. The nurse should have the father undress the child as needed during the examination.
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 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.