Ch. 6 Wong's - Evolve Case Study - Case #2: Pediatric Assessment Exam Questions And Answers

Jessica is a 3-year-old child who is brought to the clinic for a well-child visit. As you approach Jessica, you notice that she is clinging to her mother and crying inconsolably. The mother is talking softly to Jessica, assuring her that everything will be OK. - ANS Based on your knowledge of child development, the most appropriate start to the nursing assessment is: A. Begin the assessment without allowing time for play or becoming acquainted B. Gradually focus on the child or a favorite object, such as a favorite doll or toy C. Remove the child from the mother's arms and proceed with the assessment in a head-to-toe manner D. Ask the mother to leave the room if the child does not stop crying - ANS B. Gradually focus on the child or a favorite object, such as a favorite doll or toy Rationale: Gradually focus your attention on the child or favorite object, such as a doll. When assessing children, the orderly sequence is frequently altered to accommodate the child's developmental needs. Using each body system accomplishes the following goals: minimizes stress and anxiety associated with assessment of various body parts; fosters a trusting nurse-child-parent relationship; allows for maximum preparation of the child; preserves the essential security of the parent-child relationship, especially with young children; and maximizes the accuracy and reliability of the assessment findings. When taking Jessica's vital signs, you note that Jessica's blood pressure (BP) is 135/85 mm Hg. Which is/are appropriate action(s) to take? (Select all that apply.) A. Confirm that you are using the appropriately sized cuff B. Calm the child; then allow for touch and examination of the BP equipment C. Repeat the BP when the child is less anxious and agitated D. Disregard BP monitoring because it is not recommended for a 3-year-old child - ANS A, B, C A. Confirm that you are using the appropriately sized cuff B. Calm the child; then allow for touch and examination of the BP equipment C. Repeat the BP when the child is less anxious and agitated Rationale: BP should be measured annually in children 4 years of age through adolescence. No matter what type of noninvasive technique is used, the most important factor in accurately measuring BP is using the appropriately sized cuff. When children are anxious, the BP can be elevated. It is helpful to measure BP before performing any invasive procedures. Allowing the anxious child to feel the stethoscope bell or BP cuff can help calm their fears. When auscultating Jessica's heart, adventitious sounds in addition to the normal heart sounds are noted. What is your next action? A. Auscultate the heart with the child in at least two positions, sitting and reclining B. Auscultate the heart with the child sitting, reclining, standing, leaning forward, and lying on the left side C. Listen to each sound at one spot on the chest D. Refer to a cardiologist - ANS B. Auscultate the heart with the child sitting, reclining, standing, leaning forward, and lying on the left side Rationale: When adventitious sounds are detected during auscultation of the heart, further evaluation with the child standing, sitting, leaning forward, and lying on the left side helps differentiate a normal arrhythmia in children from an abnormal arrhythmia. Different types of murmurs are accentuated in different positions. After completion of the physical examination and physiologic measurements, the mother asks what other tests are necessary for Jessica now that she is 3 years old. What is your reply? A. It is recommended that she have a vision test and an eye and a dental examination. B. She needs an Hib and polio vaccination. C. It is recommended that she have an eye and hearing examination. D. No other examinations or tests are necessary at this time. - ANS A. It is recommended that she have a vision test and an eye and a dental examination. Rationale: All major authorities recommend a vision test, eye examination, and dental examination. The Hib vaccine series should be completed by 15 months of age, and the IPV is not required until 4 years of age.