ATI LPN
Wong's Essentials of Pediatric Nursing 11th Edition Test Bank
Chapter 4 : Communication and Physical Assessment of the Child and Family Questions
Question 1 of 5
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?
Correct Answer: A
Rationale: It is appropriate to give older school-age children the option of having the parent present or not. During the examination, the nurse should respect the childs need for privacy. Children who are 10 years old are minors, and parents are responsible for health care decisions. The mother of a 10-year-old child would not be uncomfortable. The child should help determine who is present during the examination.
Question 2 of 5
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?
Correct Answer: C
Rationale: Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children who are greater than or equal to the 95th percentile are considered overweight. Children whose BMI is between the 10th and 75th percentiles are within normal limits.
Question 3 of 5
Rectal temperatures are indicated in which situation?
Correct Answer: B
Rationale: Rectal temperatures are recommended when definitive measurements are necessary in infants older than age 1 month. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.
Question 4 of 5
What is the earliest age at which a satisfactory radial pulse can be taken in children?
Correct Answer: B
Rationale: Satisfactory radial pulses can be taken in children older than 2 years. In infants and young children, the apical pulse is more reliable.
Question 5 of 5
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?
Correct Answer: B
Rationale: If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff.