Which interviewing strategy should the nurse implement with a childs parents during an in home visit for physical assessment quizlet?
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*Avoid scolding the patient. Show
Rationale: Examination of the abdomen is performed correctly by the nurse in which order? a. Inspection, palpation, percussion, and auscultation b. Inspection, percussion, auscultation, and palpation c. Palpation, percussion, auscultation, and inspection d. Inspection, auscultation, percussion, and palpation
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Terms in this set (49)The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? Introduce himself or herself Which is considered a block to effective communication? Using cliches Which is the single most important factor to consider when communicating with children? Child's developmental level Because children younger than 5 years are egocentric, the nurse should do which when communicating with them? Focus communication on the child The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? The child may think the equipment is alive When the nurse interviews an adolescent, which is especially important? Allow an opportunity to express feelings. The nurse is preparing to assess a 10-month-old infant. He is sitting on his father's 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? Initiate a game of peek-a-boo An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which? Explain in simple terms how it works The nurse is having difficulty communicating with a hospitalized 6-year-old child. Which technique should be most helpful? Provide supplies for the child to draw a picture Which data should be included in a health history? Review of systems The nurse is taking a health history of an adolescent. Which best describes how the chief complaint should be determined? Ask the adolescent, "Why did you come here today?" The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading? History Where in the health history does a record of immunizations belong? History The nurse is taking a sexual history on an adolescent girl. Which is the best way to determine whether she is sexually active? Ask her, "Are you having sex with anyone?" 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? Providing sufficient amino acids Which parameter correlates best with measurements of total muscle mass? Upper arm circumference 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? Appropriate because of child's age 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? 85th percentile Rectal temperatures are indicated in which situation? Whenever accuracy is essential What is the earliest age at which a satisfactory radial pulse can be taken in children? 2 years The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which? Use the large cuff Where is the best place to observe for the presence of petechiae in dark-skinned individuals? Oral mucosa 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? Schedule the child for further evaluation The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action? Refer for immediate medical evaluation During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which? A normal finding Which explains the importance of detecting strabismus in young children? Amblyopia, a type of blindness, may result. Which is the most frequently used test for measuring visual acuity? Snellen letter chart The nurse is testing an infant's visual acuity. By which age should the infant be able to fix on and follow a target? 3-4 months During an otoscopic examination on an infant, in which direction is the pinna pulled? Down and back What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child? Pure tone audiometry What is the appropriate placement of a tongue blade for assessment of the mouth and throat? Side of the tongue When assessing a preschooler's chest, what should the nurse expect? Movement of the chest wall to be symmetric bilaterally and coordinated with breathing When auscultating an infant's lungs, the nurse detects diminished breath sounds. What should the nurse interpret this as? An abnormal finding warranting investigation Which type of breath sound is normally heard over the entire surface of the lungs except for the upper intrascapular area and the area beneath the manubrium? Vesicular The nurse is assessing a child's capillary refill time. This can be accomplished by doing what? Palpate the nail bed with pressure to produce a slight blanching. Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? Murmur Examination of the abdomen is performed correctly by the nurse in which order? Inspection, auscultation, percussion, and palpation Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is most likely to minimize this sensation and promote relaxation? Have the child "help" with palpation by placing his or her hand over the palpating hand. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is which? Normal because the lower back and leg muscles are not yet well developed The nurse is caring for a non-English-speaking child and family. Which should the nurse consider when using an interpreter? Communicate directly with family members when asking questions. Which action should the nurse implement when taking an axillary temperature? Place the tip of the thermometer under the arm in the center of the axilla. The nurse is aware that skin turgor best estimates what? Adequate hydration The Asian parent of a child being seen in the clinic avoids eye contact with the nurse. What is the best explanation for this considering cultural differences? The parent is showing respect for the nurse. The nurse is performing an otoscopic examination on a child. Which are normal findings the nurse should expect? (Select all that apply.) Well-defined light reflex Small, round, concave spot near the center of the drum Whitish line extending from the umbo upward to the margin of the membrane The nurse is assessing breath sounds on a child. Which are expected auscultated breath sounds? (Select all that apply.) Vesicular Bronchial Bronchovesicular The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.) Lightly brush the palate with a cotton swab Perform the exam in front of a mirror Let the child examine someone else's mouth first have the child breathe deeply and hold his/her breath Which are effective auscultation techniques? (Select all that apply.) Use a symmetric and orderly approach Warm the stethoscope before placing it on the skin The nurse is assessing heart sounds on a school-age child. Which should the nurse document as abnormal findings if found on the assessment? (Select all that apply.) S4 heart sound Grade II murmur S2 louder than S1 in the aortic area The nurse understands that blocks to therapeutic communication include what? (Select all that apply.) 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