NUR 2633 MCH Exam 3 Maternal Child Health Nursing

Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 952 Feedback: A Denver Developmental Screening Test (A Denver II) is well standardized. As its name implies, it measures development, not IQ. A parent is encouraged to watch. 12. Which of the following statements best explains the principle behind a Rinne test for determining hearing loss? A) Air conduction of sound is normally better than bone conduction of sound. B) Conduction of sound is intensified in the middle of the forehead. C) A tuning-fork vibration will not be heard as sound in a child under 2 years of age. D) Bone conduction of sound is normally better than air conduction of sound. Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 951 Feedback: Because air conduction of sound is better than bone conduction, a child will hear a tuning fork in front of the ear after he or she no longer hears it when placed against the bone behind the ear. 13. While caring for a child recovering from viral pneumonia, the nurse examines his lungs for evidence of exudate and fluid. Which finding would suggest cause for concern? A) A respiratory rate of 20 heard on auscultation B) Dullness of his lower lobes heard on percussion C) A longer inspiratory than expiratory rate noticed by inspection D) Fine rhonchi heard in the upper lobe on auscultation Ans: B Client Needs: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Apply Page: 937 Feedback: Dullness of lower lungs suggests they are filled with fluid and not aerating fully. 14. A 6-month-old is admitted to the hospital because of a fever. When you obtain a health history, what data would you obtain first? A) Details about the fever B) Family profile C) History of past illnesses D) Review of systems Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 919 Feedback: Health interviews typically begin with a history of the chief complaint, because this is what people want to talk about first and represents a primary health problem. 15. When assessing for bowel sounds, which statement is true? A) All four quadrants should be auscultated in a consistent pattern. B) The presence of high-frequency sounds at 5- to 10-second intervals is abnormal. C) Bowel sounds should be heard at a rate of 80 to 90 per minute in the lower quadrants. D) Bowel sounds should be audible by the naked ear unless distention is present. Ans: A Client Needs: Health Promotion and Maintenance Cognitive Level: Understand Page: 940 Feedback: Listening to all four quadrants reveals that bowel sounds are present throughout the intestine. 16. The nurse is beginning a health history with a 3-year-old child. Which question would the nurse ask the mother first? A) "Is your child ill in any way?" B) "Tell me about your child." C) "Has your child been ill in the past?" D) "Do you have any concerns about your child?" Ans: D Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Analyze Page: 920 Feedback: The most appropriate question to begin a health history is open-ended. This type of question allows the parent to elaborate on the health of the child. Close-ended questions such as asking if the child has been ill or if the child has been ill in the past limit the amount of information learned for the history. Expansive statements such as "tell me about your child" are too vague. Multiple Selection 17. The nurse is identifying ways to support the 2020 National Health Goals during the upcoming preschool health screening program. What should the nurse include when conducting the program? Select all that apply. A) Conduct vision tests. B) Conduct hearing tests. C) Listen to heart sounds. D) Measure gait and balance. E) Review immunizations received. Ans: A, B, E Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 915 Feedback: To support the 2020 National Health Goals related to health assessment of children, the nurse should participate actively in health assessment, including vision and hearing, and screening for and administering vaccines. Listening to heart sounds and measuring gait and balance do not support the 2020 National Health Goals related to health assessment of children. Multiple Choice 18. The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information? A) Ask the parents to complete a day history. B) Ask the parents to name the games the child knows. C) Ask the child how much time the mother is with the child. D) Ask the parents how many hours is spent playing with the child each day. Ans: A Client Needs: Safe, Effective Care Environment: Management of Care Cognitive Level: Apply Page: 917 Feedback: The child's current skills, sleep patterns, hygiene practices, eating habits, and interactions with the family can all be elicited by asking a parent to describe a typical day. Day histories are fun to obtain because most parents are eager to describe their day with their child, and information gained this way is surprisingly rich and pertinent, much more so than if parents are just asked how their child sleeps, eats, or plays. 19. The nurse is preparing to measure the head circumference of a 6-month-old child. How should the nurse make this measurement? A) From the hairline in front to the hairline in back B) From the center of the forehead to the base of the occiput C) Above the eyebrows through the prominent part of the occiput D) From the middle of the forehead through the parietal prominences Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 929 Feedback: Head circumference is measured by placing a tape measure around an infant's head just above the eyebrows and around the most prominent portion of the back of the head or the occipital prominence. Head circumference is not measured using the hairline or the forehead. 20. The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first? A) Palpation B) Inspection C) Percussion D) Auscultation Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 923 Feedback: To assess an abdomen, first inspect the surface for symmetry and contour. After inspection, the nurse should auscultate for bowel sounds. The examination concludes with percussion and palpation. 21. The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the nurse determine as being normal for this client? A) Stridor B) Crackles C) Rhonchi D) Wheezing Ans: C Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 938 Feedback: Rhonchi are snoring sounds that are made by air moving through mucus in the bronchi. This is a normal sound. Stridor is a crowing sound being made through a constricted larynx. This is an abnormal sound. Crackles are sounds made by air moving through fluid. This is an abnormal sound. Wheezing is a whistling sound made by air moving through a narrow bronchus. This is an abnormal sound. 22. The nurse is preparing care for a preschool-age child scheduled for a health history and physical assessment. At which point will the nurse determine a nursing diagnosis that is appropriate for the child's care? A) Prior to the assessment B) At the time of assessment C) After completing the review of systems D) After specific problems have been identified Ans: B Client Needs: Safe, Effective Care Environment: Management of Care Client Needs 2: Health Promotion and Maintenance Cognitive Level: Apply Page: 915 Feedback: Nursing diagnosis related to health assessment most commonly address a health concern identified at the time of the assessment. When establishing nursing diagnoses, do not overlook diagnoses that accentuate the healthy functioning of a child and family, even when diagnoses that address specific problems have been identified. Wellness diagnoses are crucial components of the entire assessment picture. The nurse cannot identify diagnoses before the assessment occurs. 23. The nurse is preparing to conduct a physical examination of a 3-year-old child. Which assessment will the nurse introduce for the first time to this client? A) Snellen vision testing B) Blood pressure recording C) Observation of walking gait D) Standing height measurement Ans: B Client Needs: Health Promotion and Maintenance Cognitive Level: Apply Page: 924 Feedback: Blood pressure measurement begins to be a part of routine assessment at 3 years of age. The preschool E-chart is used for vision screening at this age. Walking gait and standing height measurement will be introduced in future assessments. 24. During a pre