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A nurse is completing a health history form with a child who is 10 years of age. Which of the following information should the nurse include in the assessment? (Select All that Apply.)

Academic achievements

Response to stress

Information multiple sources

Heart and lung sounds

Child's statements with parent input

Answer and Explanation

Correct Answer : A,B,D,E

A. Academic achievements provide insight into cognitive and social development.

B. Understanding how the child responds to stress is essential for evaluating emotional and psychological well-being.

C. Information from multiple sources may be helpful, but it's not a standard requirement for routine health history.

D. Physical assessment, including heart and lung sounds, is a crucial part of a health history.

E. The child’s statements, along with parental input, offer a comprehensive view of the child’s health and developmental status.

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Correct Answer is C

Explanation

A. Cuff size recommendations vary based on the child’s arm circumference, not a specific range for all school-aged children.

B. The cuff should fit snugly around the child's arm, not loosely, to obtain an accurate reading.

C. Blood pressure is typically measured over the brachial artery using a manual or automated cuff.

D. Routine blood pressure screening usually begins at age 3 unless there are specific indications to begin earlier.

A. Heart rate B. Respiratory rate C. Urine output D. Mucous membranes E. Abdominal examination F. Vomiting frequency

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Heart rate: Not changed

No specific mention of heart rate changes, so it remains unchanged.

Respiratory rate: Not changed

Respirations are described as clear and shallow, with no significant change noted over time. The child's respiratory rate appears stable.

Urine output: Improved

Initially, the output was 8 mL of concentrated urine over 2 hours, and by 1600, the output increased to 30 mL of yellow urine over 2 hours. The improvement in both the volume and color indicates that hydration status is improving.

Mucous membranes: Improved

At 1000, the mucous membranes were described as pale and dry. By 1200, they were pale and sticky, which is still a sign of dehydration, but by 1600, they are likely improving as the child is receiving intravenous fluids and hydration.

Abdominal examination: Not changed

The abdominal examination remains consistent, with mild tenderness on palpation and hyperactive bowel sounds observed throughout the shift. These findings indicate that the child is still experiencing gastrointestinal upset but without significant worsening.

Vomiting frequency: Improved

Vomiting frequency decreased from 8 times in the previous 24 hours to just 1 episode in the past 2 hours, indicating a significant improvement in vomiting control.

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A nurse is completing a health history form with a child who is 10 years of age. Which of the following information should the nurse include in the assessment? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about assessing children's blood pressure. Which of the following statements made by the newly licensed nurse demonstrates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse in the emergency department is caring for a toddler. Exhibits The nurse is reviewing the toddler's nurses' notes, vital signs, and intake and output record. For each clinical finding, click to specify if the finding indicates the condition has improved, has not changed, or has declined.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

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