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NurseDive Free Nursing Practice Question
A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?
A. Have the child bend forward at the waist and check for asymmetry of the scapula.
"Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. Auscultate the abdomen for at least 1 min if bowel sounds are absent.
"Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. Use the FACES scale to assess pain.
"Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. Observe abdominal movement to determine the respiratory rate.
"Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.
This question is an excerpt from Nurse Dive's nursing test bank - Ati rn paediatrics nursing proctored exam 2023. Take the full exam now
Full Explanation
A. "Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. "Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. "Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. "Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.
Similar Questions
A nurse is teaching the parent of an infant about car seat safety. Which of the following instructions should the nurse include?
A. "Keep the car seat in a rear-facing position until your infant is 2 years old."
"Keep the car seat in a rear-facing position until your infant is 2 years old." The American Academy of Pediatrics (AAP) recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the height and weight limits specified by the car seat manufacturer for optimal safety.
B. "Fasten the harness over your infant's winter coat."
"Fasten the harness over your infant's winter coat." Bulky clothing (such as winter coats) should not be worn under the harness because it can create excess space, reducing the effectiveness of the restraint and increasing injury risk. Instead, the infant should be dressed in thin layers, and a blanket can be placed over the secured harness if warmth is needed.
C. "Ensure the airbag is activated if the car seat is in the front passenger seat."
"Ensure the airbag is activated if the car seat is in the front passenger seat." Infants should never be placed in the front passenger seat if the car has an active airbag. Airbags can cause severe injury or death if deployed while a rear-facing car seat is in place. The safest position is always in the back seat.
D. "Pad the backrest of the car seat with a thick blanket before securing your infant."
"Pad the backrest of the car seat with a thick blanket before securing your infant." Additional padding should not be used, as it can interfere with the proper fit of the harness and compromise safety. Car seats are designed to provide adequate support and protection without extra cushioning.
Full Explanation
A. "Keep the car seat in a rear-facing position until your infant is 2 years old." The American Academy of Pediatrics (AAP) recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the height and weight limits specified by the car seat manufacturer for optimal safety.
B. "Fasten the harness over your infant's winter coat." Bulky clothing (such as winter coats) should not be worn under the harness because it can create excess space, reducing the effectiveness of the restraint and increasing injury risk. Instead, the infant should be dressed in thin layers, and a blanket can be placed over the secured harness if warmth is needed.
C. "Ensure the airbag is activated if the car seat is in the front passenger seat." Infants should never be placed in the front passenger seat if the car has an active airbag. Airbags can cause severe injury or death if deployed while a rear-facing car seat is in place. The safest position is always in the back seat.
D. "Pad the backrest of the car seat with a thick blanket before securing your infant." Additional padding should not be used, as it can interfere with the proper fit of the harness and compromise safety. Car seats are designed to provide adequate support and protection without extra cushioning.
A nurse is caring for a 6-month-old infant who has a subdural hematoma. Which of the following findings should the nurse expect?
A. Pinpoint pupils
"Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.
B. Sunken anterior fontanel
"Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.
C. Hypertonia
"Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).
D. Vomiting
"Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.
Full Explanation
A. "Pinpoint pupils." A subdural hematoma typically causes unequal or dilated pupils due to increased intracranial pressure (ICP), rather than pinpoint pupils, which are more commonly associated with opioid toxicity or pontine damage.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration. In cases of increased ICP, as seen with a subdural hematoma, the anterior fontanel is more likely to be bulging.
C. "Hypertonia." Neurological changes can occur, but hypotonia (decreased muscle tone) is more common in infants with increased ICP rather than hypertonia (increased muscle tone).
D. "Vomiting." Vomiting is a classic sign of increased ICP in infants, which occurs due to the pressure on the brainstem. Other symptoms may include irritability, a bulging fontanel, seizures, and lethargy.
A nurse is providing teaching to an adolescent who has vulvovaginitis. Which of the following statements should the nurse include in the teaching?
A. "Apply scented baby powder to absorb residual moisture."
"Apply scented baby powder to absorb residual moisture." Scented products can irritate the vaginal area and worsen symptoms of vulvovaginitis. Instead, keeping the area dry and clean is recommended.
B. "Apply a warm, moist compress three times per day."
"Apply a warm, moist compress three times per day." Warm compresses help soothe irritation and reduce inflammation associated with vulvovaginitis.
C. "Wear a feminine deodorant pad for vaginal drainage."
"Wear a feminine deodorant pad for vaginal drainage." Deodorant pads contain chemicals that can further irritate the area. Instead, using unscented pads or breathable cotton underwear is recommended.
D. "Wear nylon underwear at night."
"Wear nylon underwear at night." Nylon traps moisture and heat, which creates an environment for bacterial and fungal growth. Instead, wearing loose-fitting cotton underwear or sleeping without underwear is recommended to promote airflow and prevent irritation.
Full Explanation
A. "Apply scented baby powder to absorb residual moisture." Scented products can irritate the vaginal area and worsen symptoms of vulvovaginitis. Instead, keeping the area dry and clean is recommended.
B. "Apply a warm, moist compress three times per day." Warm compresses help soothe irritation and reduce inflammation associated with vulvovaginitis.
C. "Wear a feminine deodorant pad for vaginal drainage." Deodorant pads contain chemicals that can further irritate the area. Instead, using unscented pads or breathable cotton underwear is recommended.
D. "Wear nylon underwear at night." Nylon traps moisture and heat, which creates an environment for bacterial and fungal growth. Instead, wearing loose-fitting cotton underwear or sleeping without underwear is recommended to promote airflow and prevent irritation.