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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.
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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.
Where in the health history does a record of immunizations belong?
- A. History
- B. Present illness
- C. Review of systems
- D. Physical assessment
Correct Answer: A
Rationale: The history contains information relating to all previous aspects of the childs health status. The immunizations are appropriately included in the history. The present illness, review of systems, and physical assessment are not appropriate places to record the immunization status.
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.
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.
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.