Exam 4: Communication, physical, and Developmental Assessment

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?

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?

Which data should be included in a health history?

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?

The nurse is testing an infant's visual acuity.By which age should the infant be able to fix on and follow a target?

The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?

Which parameter correlates best with measurements of total muscle mass?

The nurse is assessing a child's capillary refill time.This can be accomplished by doing what?

The nurse is assessing heart sounds on a school-age child.Which should the nurse document as abnormal findings if found on the assessment?

The nurse is having difficulty communicating with a hospitalized 6-year-old child.Which technique should be most helpful?

The nurse is assessing breath sounds on a child.Which are expected auscultated breath sounds?

Where is the best place to observe for the presence of petechiae in dark-skinned individuals?

Where in the health history does a record of immunizations belong?

What is the earliest age at which a satisfactory radial pulse can be taken in children?

Which is the single most important factor to consider when communicating with children?

Rectal temperatures are indicated in which situation?

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?

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?

Which action should the nurse implement when taking an axillary temperature?

Which heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?