HA Chapter 27

A. Caregiver reports that the child is not yet standing on tiptoe, nor running, and goes up and down stairs while sitting.

D. Using a crayon, the child is able to draw a line but not a circle, square, or rectangle.

The nurse documents the following data on a 2-year-old’s development. Select the developmental milestones that require further assessment for this age child. (Select all that apply.)

A. Caregiver reports that the child is not yet standing on tiptoe, nor running, and goes up and down stairs while sitting.

B. The child is speaking in full sentences of four to five words and able to identify major body parts.

C. Able to identify items in picture books and recognizes some simple words in a book.

D. Using a crayon, the child is able to draw a line but not a circle, square, or rectangle.

E. The caregiver notes that the child will follow three to four step commands and likes to mimic the caregiver.

C. Pull the pinna down and back.

The nurse is preparing to assess the tympanic membrane of a 5-year-old child. Which method will the nurse use to visualize the inner ear?

A. Pull the top of the pinna toward the face.

B. Pull the side of the pinna upward.

C. Pull the pinna down and back.

D. Pull the pinna straight back.

C. Parent’s Evaluation of Developmental Milestones

The nurse is performing an assessment on a 15-month-old child. The caregiver reports concerns that the child may not be developing physically at the same rate as other children. The nurse will utilize a developmental screening tool to further assess the caregiver’s report. Which tool is most appropriate for this child?

A. Pediatric Symptom Checklist

B. Strengths and Difficulties Questionnaire

C. Parent’s Evaluation of Developmental Milestones

D. Ages and Stages Questionnaire: Social–Emotional

A. Measure the height using a stand-up scale.

D. Calculate the BMI and plot on the appropriate chart.

F. Measure the weight using a stand-on scale.

The nurse is assessing a 5-year-old child. Which anthropometric assessments are included for this child? (Select all that apply.)

A. Measure the height using a stand-up scale.

B. Use a manual cuff to auscultate the BP.

C. Measure the head circumference with a standard tape measure.

D. Calculate the BMI and plot on the appropriate chart.

E. Palpate the radial artery to measure heart rate.

F. Measure the weight using a stand-on scale.

B. Diminished femoral pulses

D. Abnormal second heart sound (S2)

F. Increased intensity of the murmur with standing

The nurse is assessing a child’s heart and notes a murmur. The nurse suspects an abnormal murmur. What signs and symptoms suggest the murmur may be abnormal? (Select all that apply.)

A. Soft vibratory humming sound

B. Diminished femoral pulses

C. Sound disappears when the child stands

D. Abnormal second heart sound (S2)

E. Brief and localized sound at the left sternal border

F. Increased intensity of the murmur with standing

C. Evaluate the BP based on established percentiles for age, sex assigned at birth, and height.

A nurse is assessing the BP of a 5-year-old child. The reading obtained is 110/70 mm Hg (left arm). What will the nurse do next regarding this BP reading?

A. Document the finding and provide a referral for follow-up with a specialist.

B. Have the caregiver bring the child for a return visit in a week to recheck the BP.

C. Evaluate the BP based on established percentiles for age, sex assigned at birth, and height.

D. Take the BP on the other arm and compare the findings.

B. 4 years

The nurse is preparing to take a health history. The nurse recognizes that a child of what age is ready to participate in the interview process and the nurse should begin to ask the child questions in addition to the caregiver?

A. 2 years

B. 4 years

C. 6 years

D. 8 years

A. Children age 4 and older who weigh at least 40 lb can be in a booster seat.

The nurse is providing information on the use of car seats. The nurse should include which information on the use of car seats for children?

A. Children age 4 and older who weigh at least 40 lb can be in a booster seat.

B. Children should remain in the rear seat until they have outgrown the booster seat.

C. The use of car seats is a mandatory law that is standard across the country.

D. A forward-facing seat is used for children after the age of 12 months.

B. Psychological/behavioral screening

C. Developmental screening

D. Autism spectrum disorder screening

The nurse is preparing to complete a health assessment on an 18-month-old child. The nurse should include which development/behavioral health screenings? (Select all that apply.)

A. Maternal depression screening

B. Psychological/behavioral screening

C. Developmental screening

D. Autism spectrum disorder screening

E. Lead screening

F. Vision screening

D. While the child is quietly sitting on the parent’s lap

What is the best time to assess the respiratory rate of a young child?

A. While the child is crying

B. While the child is playing in the playroom

C. Immediately after taking the child’s BP

D. While the child is quietly sitting on the parent’s lap