ATI – Skills Module: Physical Assessment Child

ATI – Skills Module: Physical Assessment Child

Which of the following communication techniques is most appropriate for a nurse to employ during the physical examination of a 10 year old?
-Allow the child to play with the equipment
-Encourage expression of thought through puppets.
-Use books and other visual aids to advance the interview.
-Use abstract questions to allow the child more freedom in response.
X – Allow the child to play with the equipment. (This technique is best used with preschoolers.)
X – Encourage expression of thought through puppets. (This technique is best used with toddlers.)
~ USE BOOKS AND OTHER VISUAL AIDS TO ADVANCE THE INTERVIEW. (This technique is very useful for working with school-age children.)
x – Use abstract questions to allow the child more freedom in response. (Abstract thinking does not develop until adolescence.)
A nurse is testing a child for strabismus. Which of the following is the correct technique for performing this examination?
-Check for presence of the red reflex
-Check for visual acuity.
-Perform the cover-uncover test.
-Test for pupillary reaction to light.
X – Check for presence of the red reflex. (This test examines the lens of the eye, not whether the child has strabismmus.)
X – Check for visual acuity. (A visual acuity examination is not used to determine whether a child has strabismus.)
~ PERFORM THE COVER-UNCOVER TEST. (This test identifies whether the child has strabismus, or nonbinocular vision.)
X – Test for pupillary reaction to light. (How the pupils react to light is not used to determine whether a child has strabismus.)
A nurse is performing an annual examination on an adolescent. Which of the following could be included in the general servery?
-The patient’s DTRs are 2+ bilaterally.
-The patient is able to read small print at 14 inches.
-The patient demonstrates short-term recall.
-The patient makes good eye contact.
X – The patient’s DTRs are 2+ bilaterally. (DTRs are examiened during a neuro examination.)
X – The patient is able to read small print at 14 inches. (Visual acuity is examined during a neuro examination.)
X – The patient demonstrates short-term recall. (Short term recall is examined during a mental status examination.)
~ THE PATIENT MAKES GOOD EYE CONTACT. (This information is included in the general survey. The general survey includes indentifying the patient’s demeanor, mood, and interactions with others.)
When performing an otoscopy examination on a 2-year-old child, the nurse should pull the pinna
-down and back
-down and forward
-up and back
-up and forward
~ DOWN AND BACK (This is correct technique for straightening the ear canal because the ear canal of a 2 year old curves upwards.)
X – Down and forward (This technique is inappropriate for examining the ear of a child of any age.)
X – Up and back (This is correct technique for straightening the ear canal for children 3 years and older.)
X – Up and forward (This technique is inappropriate for examining the ear of a child of any age.)
A nurse is documenting
-Bowel gurgling at 24 per minute, heart in left upper quadrant, right upper quadrant, left lower quadrant, and right lower quadrant.
-no problems breathing. Lung clear
-Liver palpation normal.
-regular heart rate and rhythm. S1, S2 heard.
X – Bowel gurgling at 24 per minute, heart in left upper quadrant, right upper quadrant, left lower quadrant, and right lower quadrant. (“Bowel gurgling” is not appropriate terminology. The location of the bowel sounds can be summarized as “all four quadrants.”)
X – No problems breathing. Lung clear. (“No problems breathing” does not give specific information about rate and rhythm of respiration. Also, location of lung sounds should be documented.)
X – Liver palpation normal. (The term “normal” should be avoided when documenting physical assessment findings, as there are different interpretations of “normal.”)
~ REGULAR HEART RATE AND RHYTHM: S1, S2 HEARD. (This is clear, concise charting for normal heart sounds.)
A nurse is obtaining a problem-oriented history from a preschool-age child. The nurse should consider that children from this age group typically can:
-describe the symptoms
-identify when the problem started
-specify the cause of the problem
-answer questions related to previous health problems
~ DESCRIBE THE SYMPTOMS. (Preschoolers are usually able to describe symptoms of their problem.)
X – Identify when the problem started. (Preschoolers have varied concepts of time.)
X – Specify the cause of the problem. (Preschoolers typically do not have an understanding of cause and effect.)
X – Answer questions related to previous health problems. (Preschoolers typically do not have a reliable recall of previous health problems.)
A nurse is performing an abdominal examination of a preschooler. Which of the following instructions should the nurse give to the child when performing abdominal palpation?
-Hold your breath.
-Place your hand under mine.
-Turn on your right side.
-Raise your arms over your head.
X – Hold your breath. (Taking a deep breath can help the child relax, but holding the breath can increase anxiety as the child wants to inhale.)
~ PLACE YOUR HAND UNDER MINE (Allowing the child to touch her abdomen during the examination will promote relaxation.)
X – Turn on your right side.(The lateral position is not appropriate for abdominal palpation.)
X – Raise your arms over your head. (Raising the arms over the head makes palpation difficult because the abdominal wall is stretched and tightened.)
A nurse is examining an 18-month-old child during a well-child visit. Which of the following techniques should the nurse use?
– Position the child on his side and have the parents hold the arms and head down.
-Have the parents hold the child securely in her lap.
-Ask another nurse to come into the room and hold the child.
-Restrain the child using a blanket to secure his arms against his sides.
X – Position the child on his side and have the parents hold the arms and head down. (This technique might increase fear and discomfort.)
~ HAVE THE PARENT HOLD THE CHILD SECURELY IN HER LAP. (The parent’s lap is the most comfortable and secure position for the child.)
X -Ask another nurse to come into the room and hold the child. (Asking a stranger to hold the child might increase the child’s fear.)
-Restrain the child using a blanket to secure his arms against his sides. (Use of physical restraint is a last resort and not appropriate for a routine examination.)
Which of the following techniques is appropriate when measuring a blood pressure on a child?
-Position the arm.
-Release the cuff.
-Inflate the blood pressure cuff slowly.
-use a cuff with a bladder covering 80-100% of the arm circumference
X – Position the arm below the level of the heart while the child is sitting in a chair. (The arm should be positioned at the level of the heart.)
X – Release the cuff pressure at a rate of 4-5 mm Hg. (The cuff pressure should be released at a rate of 2 – 3 mm Hg.)
X – Inflate the blood pressure cuff slowly. (The cuff should be inflated rapidly.)
~ USE A CUFF WITH A BLADDER COVERING 80-100% OF THE ARM CIRCUMFERENCE. (The bladder should cover 80-100% of the arm circumference to obtain an accurate reading.)
When assessing a school-age child for scoliosis, it is important to have the child:
-bend the knees and touch the toes
-stand up straight with the arms at the side
-bend forward with the knees straight and the arms dangling
-lie prone with the arms extended.
X – Bend the knees and touch the toes. (Touching the toes angles the spine downwards.)
X – Stand up straight with the arms at the side. (This position does not allow the spine to be parallel to the floor.)
~ BEND FORWARD WITH THE KNEES STRAIGHT AND THE ARMS DANGLING. (This position allows for adequate visualization of any asymmetry.)
X – Lie prone with the arms extended. (The prone position does not allow adequate visualization of any asymmetry.)