What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?

Correct Answer: C

Rationale: In the context of pediatric nursing, conducting hearing screenings in children is crucial for early detection of hearing impairments. The appropriate screening test for hearing in a 5-year-old child is option C, Pure tone audiometry. This test is chosen because it is specifically designed to assess the hearing threshold levels in children by measuring their ability to hear different frequencies. Option A, the Rinne test, and option B, the Weber test, are both tests used to differentiate between conductive and sensorineural hearing loss in adults and are not suitable for hearing screening in young children. Option D, eliciting the startle reflex, is not a reliable or standardized method for hearing screening in children. It may indicate a response to sound but does not provide accurate information about the child's hearing thresholds across different frequencies. Educationally, understanding the appropriate screening tools for various age groups is essential for nurses working in pediatric settings to ensure early detection and intervention for any hearing impairments that could impact a child's development. Conducting regular screenings using appropriate methods can help in identifying issues early and providing timely support and interventions.

Correct Answer: D

Rationale: In assessing a preschooler's chest, the nurse should expect symmetric bilateral movement of the chest wall that is coordinated with breathing. This is the correct answer (D) because in a healthy preschooler, the chest wall should move symmetrically with each breath, indicating proper respiratory function. This finding is crucial in determining adequate ventilation and potential respiratory issues. Option A is incorrect because preschoolers typically have abdominal or diaphragmatic breathing rather than chiefly thoracic breathing. Option B is incorrect as the anteroposterior diameter is normally greater than the transverse diameter in preschoolers due to their immature chest structure. Option C is incorrect as retractions of the muscles between the ribs on respiratory movement would indicate respiratory distress, which is not expected in a healthy preschooler. Educationally, understanding the expected chest assessment findings in preschoolers is vital for nurses caring for this age group. Recognizing normal variations from abnormal findings can help nurses identify respiratory issues early and provide timely interventions to prevent complications. This knowledge is essential in pediatric nursing practice to ensure optimal care and outcomes for preschool-aged patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) An abnormal finding warranting investigation. Diminished breath sounds in an infant can indicate an underlying respiratory issue that requires further assessment and intervention. It is crucial for the nurse to recognize this abnormal finding to prevent potential complications and provide timely care. Option A) Suggestive of chronic pulmonary disease is incorrect because diminished breath sounds in an infant are not necessarily indicative of a chronic condition without further evaluation. Option B) Suggestive of impending respiratory failure is also incorrect as diminished breath sounds alone may not always signify impending respiratory failure but rather a need for further assessment. Option D) A normal finding in infants younger than 1 year of age is incorrect as diminished breath sounds should not be considered normal in this population without investigation. Educationally, it is essential for nurses caring for children to be able to recognize abnormal assessment findings and respond appropriately. Understanding the significance of auscultatory findings in infants is crucial for providing safe and effective care, as respiratory issues can escalate quickly in this vulnerable population. Regular skills practice and ongoing education can help nurses develop the necessary assessment skills to identify and respond to abnormalities promptly.

Correct Answer: A

Rationale: The correct answer is A) Vesicular. Vesicular breath sounds are normally heard over the entire surface of the lungs except for specific areas such as the upper intrascapular region and beneath the manubrium. These sounds are soft, low-pitched, and heard during inspiration and the beginning of expiration. Option B) Bronchial breath sounds are heard over the trachea and larynx, characterized by a high pitch and loud intensity. These sounds are not typically heard over the lung fields. Option C) Adventitious breath sounds refer to abnormal sounds such as crackles, wheezes, or pleural friction rubs. These are not normal breath sounds and are indicative of underlying respiratory issues. Option D) Bronchovesicular breath sounds are a mix of bronchial and vesicular sounds and are typically heard in specific areas of the lungs, not over the entire lung surface as described in the question. Understanding breath sounds is crucial for nurses caring for pediatric patients as abnormal findings can indicate respiratory conditions that require prompt assessment and intervention. Nurses must be skilled in differentiating normal from abnormal breath sounds to provide optimal care for children with respiratory issues.

Correct Answer: D

Rationale: In pediatric nursing, assessing capillary refill time is crucial in determining tissue perfusion and overall cardiovascular status. The correct answer is D) Palpate the nail bed with pressure to produce a slight blanching. This is because capillary refill time is a quick and effective method to assess peripheral perfusion by observing how quickly blood refills capillaries after pressure is applied and released. Option A) Inspecting the chest is incorrect as it does not relate to assessing capillary refill time. Option B) Auscultating the heart is also incorrect as it pertains to assessing cardiac function, not capillary refill. Option C) Palpating the apical pulse focuses on assessing heart rate and rhythm, not capillary refill time. Educationally, understanding how to properly assess capillary refill time in children is essential for nurses to detect early signs of inadequate tissue perfusion, such as in shock or dehydration. It helps nurses make quick clinical decisions and initiate appropriate interventions. Mastery of this skill is crucial for providing safe and effective care to pediatric patients.