Nursing interventions for hydrotherapy during labor ati

Pediatric Health Promotion Project.

RN Nursing Care of Children REVIEW MODULE EDITION 10.0

Contributors Norma Jean E. Henry, MSN/Ed, RN

Mendy McMichael, DNP, MSN

Janean Johnson, MSN, RN, CNE

Agnes DiStasi, DNP, RN, CNE

Carrie B. Elkins, DHSc, MSN

Honey C. Holman, MSN, RN

Pamela Roland, MSN, RN

Robin A. Hertel, EdS, MSN, RN, CMSRN

Kellie L. Wilford, MSN, RN

Marsha S. Barlow, MSN, RN

Consultants Judy Drumm, DNS, RN, CPN

Christi Glesmann, Ed.D, MSN, RN

Christi Blair, MSN, RN

Tomekia Earl, MSN, RN

Lakeisha Wheless, MSN, RN

INTELLECTUAL PROPERTY NOTICE ATI Nursing is a division of Assessment Technologies Institute®, LLC.

Copyright © 2016 Assessment Technologies Institute, LLC. All rights reserved.

The reproduction of this work in any electronic, mechanical or other means, now known or hereafter

invented, is forbidden without the written permission of Assessment Technologies Institute, LLC. All of the

content in this publication, including, for example, the cover, all of the page headers, images, illustrations,

graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual

property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by

third parties who have licensed their materials to Assessment Technologies Institute, LLC.

II CONTENT MASTERY SERIES

IMPORTANT NOTICE TO THE READER Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for

informational and educational purposes only and may be modified or updated by the publisher at any time. This

publication is not providing medical advice and is not intended to be a substitute for professional medical advice,

diagnosis, or treatment. The publisher has designed this publication to provide accurate information regarding the

subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to

the use of the contents of this book and makes no guarantee and assumes no responsibility or liability for the use of the

products and procedures described or the correctness, sufficiency, or completeness of stated information, opinions, or

recommendations. The publisher does not recommend or endorse any specific tests, providers, products, procedures,

processes, opinions, or other information that may be mentioned in this publication. Treatments and side effects described

in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect

that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by

the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice,

and government regulations often change the accepted standard in this field. When consideration is being given to use

of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the

drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations

on dose, precautions, and contraindications and determining the appropriate usage for the product. Any references

in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely

as a general guide. Other or additional safety measures may be required under particular circumstances. This book

is not intended as a statement of the standards of care required in any particular situation, because circumstances

and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book

shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such

specific determination should be made only with the aid of legal counsel. Some images in this book feature models.

These models do not necessarily endorse, represent, or participate in the activities represented in the images. THE

PUBLISHER MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND, WHETHER EXPRESS OR IMPLIED, WITH

RESPECT TO THE CONTENT HEREIN. THIS PUBLICATION IS PROVIDED AS-IS, AND THE PUBLISHER AND ITS AFFILIATES

SHALL NOT BE LIABLE FOR ANY ACTUAL, INCIDENTAL, SPECIAL, CONSEQUENTIAL, PUNITIVE, OR EXEMPLARY

DAMAGES RESULTING, IN WHOLE OR IN PART, FROM THE READER’S USE OF, OR RELIANCE UPON, SUCH CONTENT.

Director of content review: Kristen Lawler

Director of development: Derek Prater

Project management: Janet Hines, Nicole Burke

Coordination of content review: Norma Jean E. Henry, Mendy McMichael

Copy editing: Kelly Von Lunen, Derek Prater

Layout: Spring Lenox, Randi Hardy

Illustrations: Randi Hardy

Online media: Morgan Smith, Ron Hanson, Nicole Lobdell, Brant Stacy

Cover design: Jason Buck

Interior book design: Spring Lenox

RN NURSING CARE OF CHILDREN USER’S GUIDE III

User’s Guide Welcome to the Assessment Technologies Institute® RN Nursing Care of Children Review Module Edition 10.0. The mission of ATI’s Content Mastery Series® Review Modules is to provide user-friendly compendiums of nursing knowledge that will:

● Help you locate important information quickly. ● Assist in your learning efforts. ● Provide exercises for applying your nursing knowledge. ● Facilitate your entry into the nursing profession as a

newly licensed nurse.

This newest edition of the Review Modules has been redesigned to optimize your learning experience. We’ve fit more content into less space and have done so in a way that will make it even easier for you to find and understand the information you need.

ORGANIZATION This Review Module is organized into units covering the foundations of nursing care of children, nursing care of children who have systems disorders, and nursing care of children who have other specific needs. Chapters within these units conform to one of four organizing principles for presenting the content.

● Nursing concepts ● Growth and development ● Procedures ● System disorders

Nursing concepts chapters begin with an overview describing the central concept and its relevance to nursing. Subordinate themes are covered in outline form to demonstrate relationships and present the information in a clear, succinct manner.

Growth and development chapters cover expected growth and development, including physical and psychosocial development, age-appropriate activities, and health promotion, including immunizations, health screenings, nutrition, and injury prevention.

Procedures chapters include an overview describing the procedure(s) covered in the chapter. These chapters provide nursing knowledge relevant to each procedure, including indications, nursing considerations, interpretation of findings, and complications.

System disorders chapters include an overview describing the disorder(s) and/or disease process. These chapters address assessments, including risk factors, expected findings, laboratory tests, and diagnostic procedures. Next, you will focus on patient-centered care, including nursing care, medications, therapeutic procedures, interprofessional care, and client education. Finally, you will find complications related to the disorder, along with nursing actions in response to those complications.

ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES

Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises pose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX-style questions, such as multiple-choice and multiple-select items, providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales.

NCLEX® CONNECTIONS To prepare for the NCLEX-RN, it is important to understand how the content in this Review Module is connected to the NCLEX-RN test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, www.ncsbn. org. When reviewing content in this Review Module, regularly ask yourself, “How does this content fit into the test plan, and what types of questions related to this content should I expect?”

To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline. These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are:

● Safe and Effective Care Environment ◯ Management of Care ◯ Safety and Infection Control

● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity

◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation

An NCLEX Connection might, for example, alert you that content within a unit is related to:

● Physiological Adaptation ◯ Alterations in Body Systems

■ Identify clinical manifestations and incubation periods of infectious diseases.

IV USER’S GUIDE CONTENT MASTERY SERIES

QSEN COMPETENCIES As you use the Review Modules, you will note the integration of the Quality and Safety Education for Nurses (QSEN) competencies throughout the chapters. These competencies are integral components of the curriculum of many nursing programs in the United States and prepare you to provide safe, high-quality care as a newly licensed nurse. Icons appear to draw your attention to the six QSEN competencies.

Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.

Patient-Centered Care: The provision of caring and compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values.

Evidence-Based Practice: The use of current knowledge from research and other credible sources, on which to base clinical judgment and client care.

Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice.

Quality Improvement: Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs.

Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes.

ICONS Icons are used throughout the Review Module to draw your attention to particular areas. Keep an eye out for these icons.

This icon is used for NCLEX Connections.

This icon indicates gerontological considerations, or knowledge specific to the care of older adult clients.

This icon is used for content related to safety and is a QSEN competency. When you see this icon, take note of safety concerns or steps that nurses can take to ensure client safety and a safe environment.

This icon is a QSEN competency that indicates the importance of a holistic approach to providing care.

This icon, a QSEN competency, points out the integration of research into clinical practice.

This icon is a QSEN competency and highlights the use of information technology to support nursing practice.

This icon is used to focus on the QSEN competency of integrating planning processes to meet clients’ needs.

This icon highlights the QSEN competency of care delivery using an interprofessional approach.

This icon appears at the top-right of pages and indicates availability of an online media supplement, such as a graphic, animation, or video. If you have an electronic copy of the Review Module, this icon will appear alongside clickable links to media supplements. If you have a hard copy version of the Review Module, visit www.atitesting.com for details on how to access these features.

FEEDBACK ATI welcomes feedback regarding this Review Module. Please provide comments to comments@atitesting.com.

RN NURSING CARE OF CHILDREN TABLE OF CONTENTS V

Table of Contents

NCLEX® Connections 1

UNIT 1 Foundations of Nursing Care of Children SECTION: Perspectives of Nursing Care of Children

CHAPTER 1 Family-Centered Nursing Care 3

CHAPTER 2 Physical Assessment Findings 7

CHAPTER 3 Health Promotion of Infants (2 Days to 1 Year) 15

CHAPTER 4 Health Promotion of Toddlers (1 to 3 Years) 21

CHAPTER 5 Health Promotion of Preschoolers (3 to 6 Years) 25

CHAPTER 6 Health Promotion of School-Age Children (6 to 12 Years) 29

CHAPTER 7 Health Promotion of Adolescents (12 to 20 Years) 33

NCLEX® Connections 37

SECTION: Specific Considerations of Nursing Care of Children

CHAPTER 8 Safe Administration of Medication 39

CHAPTER 9 Pain Management 43

CHAPTER 10 Hospitalization, Illness, and Play 49

Hospitalization and illness 49

Play 50

CHAPTER 11 Death and Dying 53

VI TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections 57

UNIT 2 Nursing Care of Children Who Have System Disorders SECTION: Neurosensory Disorders

CHAPTER 12 Acute Neurological Disorders 59

Meningitis 59

Reye syndrome 61

CHAPTER 13 Seizures 65

CHAPTER 14 Head Injury 71

CHAPTER 15 Cognitive and Sensory Impairments 75

Visual impairments 75

Hearing impairments 76

Down syndrome 77

NCLEX® Connections 81

SECTION: Respiratory Disorders

CHAPTER 16 Oxygen and Inhalation Therapy 83

Pulse oximetry 83

Nebulized aerosol therapy 84

Metered‑dose inhaler or dry powder inhaler 84

Chest physiotherapy 85

Oxygen therapy 86

Suctioning 87

Artificial airways 88

CHAPTER 17 Acute and Infectious Respiratory Illnesses 91

Tonsillitis and tonsillectomy 91

Common respiratory illnesses 92

Nasopharyngitis 93

Acute streptococcal pharyngitis 94

Bronchitis (tracheobronchitis) 94

Bronchiolitis 94

Allergic rhinitis 95

Bacterial pneumonia 95

Croup syndromes 96

Acute laryngotracheobronchitis and acute spasmodic laryngitis 96

Influenza A and B 96

RN NURSING CARE OF CHILDREN TABLE OF CONTENTS VII

CHAPTER 18 Asthma 99

CHAPTER 19 Cystic Fibrosis 105

NCLEX® Connections 109

SECTION: Cardiovascular and Hematologic Disorders

CHAPTER 20 Cardiovascular Disorders 111

Congenital heart disease 111

Pulmonary artery hypertension 114

Infective (bacterial) endocarditis 114

Cardiomyopathy 115

Shock 115

Rheumatic fever 118

Dyslipidemia 119

Kawasaki disease 120

CHAPTER 21 Hematologic Disorders 123

Epistaxis 123

Iron deficiency anemia 123

Sickle cell anemia 125

Hemophilia 127

NCLEX® Connections 131

SECTION: Gastrointestinal Disorders

CHAPTER 22 Acute Infectious Gastrointestinal Disorders 133

CHAPTER 23 Gastrointestinal Structural and Inflammatory Disorders 139

Cleft lip and palate 139

Gastrointestinal reflux disease 140

Hypertrophic pyloric stenosis 141

Hirschsprung’s disease 142

Intussusception 143

Appendicitis 143

Meckel’s diverticulum 144

VIII TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections 147

SECTION: Genitourinary and Reproductive Disorders

CHAPTER 24 Enuresis and Urinary Tract Infections 149

Enuresis 149

Urinary tract infections 150

CHAPTER 25 Structural Disorders of the Genitourinary Tract and Reproductive System 153

CHAPTER 26 Renal Disorders 157

Acute glomerulonephritis 157

Nephrotic syndrome 158

Hemolytic uremic syndrome 160

Acute renal failure 161

Chronic renal failure 162

NCLEX® Connections 165

SECTION: Musculoskeletal Disorders

CHAPTER 27 Fractures 167

CHAPTER 28 Musculoskeletal Congenital Disorders 173

Clubfoot 173

Legg‑Calve‑Perthes disease 174

Developmental dysplasia of the hip (DDH) 174

Osteogenesis imperfecta 176

Scoliosis 177

CHAPTER 29 Chronic Neuromusculoskeletal Disorders 181

Cerebral palsy 181

Spina bifida 183

Juvenile idiopathic arthritis 185

Muscular dystrophy 187

RN NURSING CARE OF CHILDREN TABLE OF CONTENTS IX

NCLEX® Connections 191

SECTION: Integumentary Disorders

CHAPTER 30 Skin Infections and Infestations 193

Skin infections 193

Arthropod bites and stings 196

Skin infestations 197

CHAPTER 31 Dermatitis and Acne 201

Contact dermatitis 201

Atopic dermatitis 202

Acne 204

CHAPTER 32 Burns 207

NCLEX® Connections 213

SECTION: Endocrine Disorders

CHAPTER 33 Diabetes Mellitus 215

CHAPTER 34 Growth Hormone Deficiency 221

NCLEX® Connections 225

SECTION: Immune and Infectious Disorders

CHAPTER 35 Immunizations 227

CHAPTER 36 Communicable Diseases 235

CHAPTER 37 Acute Otitis Media 241

CHAPTER 38 HIV/AIDS 245

NCLEX® Connections 249

SECTION: Neoplastic Disorders

CHAPTER 39 Organ Neoplasms 251

CHAPTER 40 Blood Neoplasms 257

CHAPTER 41 Bone and Soft Tissue Cancers 263

Bone tumors 263

Rhabdomyosarcoma 265

X TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections 269

UNIT 3 Nursing Care of Children Who Have Other Specific Needs

CHAPTER 42 Complications of Infants 271

Phenylketonuria 271

Meningocele/Myelomeningocele 272

Necrotizing enterocolitis 274

Respiratory distress syndrome 274

Congenital hypothyroidism 275

Substance‑exposed infants 276

Hyperbilirubinemia 277

Newborn sepsis 279

Failure to thrive 280

Plagiocephaly 280

Newborn seizures 281

Complications of the preterm infant 282

Chromosomal abnormalities 283

CHAPTER 43 Pediatric Emergencies 287

Respiratory emergencies 287

Drowning 288

Apparent life‑threatening event 288

Sudden infant death syndrome 289

Poisoning 289

CHAPTER 44 Psychosocial Issues of Infants, Children, and Adolescents 293

Depression 293

Posttraumatic stress disorder 293

Attention‑deficit/hyperactivity disorder 294

Autism spectrum disorder 295

Cognitive impairment 296

Failure to thrive 296

Maltreatment of infants and children 297

Bullying 299

RN NURSING CARE OF CHILDREN TABLE OF CONTENTS XI

References 301

Active Learning Templates A1 Basic Concept A1

Diagnostic Procedure A3

Growth and Development A5

Medication A7

Nursing Skill A9

System Disorder A11

Therapeutic Procedure A13

RN NURSING CARE OF CHILDREN NCLEX® CONNECTIONS 1

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Client Needs: Safety and Infection Control ACCIDENT/ERROR/INJURY PREVENTION Identify factors that influence accident/injury prevention (e.g., age, developmental stage, lifestyle, mental status).

Identify and facilitate correct use of infant and child car seats.

Client Needs: Health Promotion and Maintenance AGING PROCESS Provide care and education for the newborn less than 1 month old through the infant or toddler client through 2 years.

Provide care and education for the preschool, school age and adolescent client ages 3 through 17 years.

DEVELOPMENTAL STAGES AND TRANSITIONS: Provide education to clients/staff members about expected age-related changes and age-specific growth and development.

TECHNIQUES OF PHYSICAL ASSESSMENT: Choose physical assessment equipment and techniques appropriate for the client.

Client Needs: Pharmacological and Parenteral Therapies

MEDICATION ADMINISTRATION: Review pertinent data prior to medication administration.

RN NURSING CARE OF CHILDREN CHAPTER 1 Family-Centered nursing Care 3

UNIT 1 FOUNDATIONS OF NURSING CARE OF CHILDREN SECTION: PERSPECTIVES OF NURSING CARE OF CHILDREN

CHAPTER 1 Family-Centered Nursing Care

Families are groups that should remain constant in children’s lives. Family is defined as what an individual considers it to be.

Families often include individuals with a biological, marital, or adoptive relationship, but in the absence of these characteristics, families also consist of individuals who have a strong emotional bond and commitment to one another.

due to the expanding concepts of family, the term household is sometimes used.

Positive family relationships are characterized by parent-child interactions that show mutual warmth and respect.

COMPONENTS OF CARE Family-centered nursing care includes the following.

● Agreed-upon partnerships between families of children, nurses, and providers, in which the families and children benefit.

● Respecting cultural diversity, and incorporating cultural views in the plan of care.

● Understanding growth and developmental needs of children and their families.

● Treating children and their families as clients. ● Working with all types of families. ● Collaborating with families regarding hospitalization,

home, and community resources. ● Allowing families to serve as experts regarding their

children’s health conditions, usual behaviors in different situations, and routine needs.

PrOmOting Family-Centered Care Nurses should perform comprehensive family assessments to identify strengths and weaknesses.

Characteristics of healthy families ● Members communicate well and listen to each other. ● There is affirmation and support for all members. ● There is a clear set of family rules, beliefs, and values. ● Members teach respect for others. ● There is a sense of trust. ● Members play and share humor together. ● Members interact with one another. ● There is a shared sense of responsibility. ● There are traditions and rituals. ● There is adaptability and flexibility in roles. ● Members seek help for their problems.

NURSING CONSIDERATIONS ● Nurses should pay close attention when family

members state that a child “isn’t acting right” or has other concerns.

● Children’s opinions should be considered when providing care.

FAMILY THEORIES

Family systems The family is viewed as a whole system, instead of the individual members.

● A change to one member affects the entire system. ● The system can both initiate and react to change. ● Too much and too little change can lead to dysfunction.

Family stress Describes stress as inevitable.

● Stressors can be expected or unexpected. ● Explains the reaction of a family to stressful events. ● Offers guidance for adapting to stress.

deVelOPmental Views families as small groups that interact with the larger social system.

● Emphasizes similarities and consistencies in how families develop and change.

● Uses Duvall’s family life cycle stages to describe the changes a family goes through over time.

● How the family functions in one stage has a direct effect on how the family will function in the next stage.

CHAPTER 1

4 CHAPTER 1 Family-Centered nursing Care CONTENT MASTERY SERIES

FAMILY COMPOSITION Traditional nuclear family: Married couple and their biologic children (only full brothers and sisters)

Nuclear family: Two parents and their children (biologic, adoptive, step, foster)

Single-parent family: One parent and one or more children

Blended family (also called reconstituted): At least one stepparent, stepsibling, or half-sibling

Extended family: At least one parent, one or more children, and other individuals (might not be related)

Gay/lesbian family: Two members of the same sex who have children and a legal or common-law tie

Foster family: A child or children who have been placed in an approved living environment away from the family of origin, usually with one or two parents

Binuclear family: Parents who have terminated spousal roles but continue their parenting roles

Communal family: Individuals who share common ownership of property and goods, and exchange services without monetary consideration

Changes that occur with the birth (or adoption) of the first child

● Parents’ sense of self as they transition to the new parental role

● Division of labor and roles within the relationships of couples

● Relationships with grandparents ● Work relationships ● Increased financial responsibilities and possible loss

of income ● Necessary sleep habit changes

PARENTING STYLES

tyPes OF Parenting

Dictatorial or authoritarian

Parents try to control the child’s behaviors and attitudes through unquestioned rules and expectations.

the child is never allowed to watch television on school nights.

Permissive

Parents exert little or no control over the child’s behaviors, and consult the child when making decisions.

the child assists with deciding whether he will watch television.

Democratic or authoritative

Parents direct the child’s behavior by setting rules and explaining the reason for each rule setting.

the child can watch television for 1 hr on school nights after completing all of his homework and chores.

Parents negatively reinforce deviations from the rules.

the privilege is taken away but later reinstated based on new guidelines.

Passive

Parents are uninvolved, indifferent, and emotionally removed.

the child may watch television whenever he wants.

guidelines FOr PrOmOting aCCePtaBle BeHaViOr in CHildren

● Set clear and realistic limits and expectations based on the developmental level of the child.

● Validate the child’s feelings, and offer sympathetic explanations.

● Provide role modeling and reinforcement for appropriate behavior.

● Focus on the child’s behavior when disciplining the child.

FAMILY ASSESSMENT History: Medical history for parents, siblings, and grandparents

Structure: Family members (mother, father, son)

Developmental tasks: Tasks a family works on as the child grows (parents with a school-age child helping her to develop peer relations)

Family characteristics: Cultural, religious, and economic influences on behavior, attitudes, and actions

Family stressors: Expected (birth of a child) and unexpected (illness, divorce, disability, or death of a family member) events that cause stress

Environment: Availability of and family interactions with community resources

Family support system: Availability of extended family, work and peer relationships, as well as social systems and community resources to assist the family in meeting needs or adapting to a stressor

RN NURSING CARE OF CHILDREN CHAPTER 1 Family-Centered nursing Care 5

Application Exercises 1. a nurse manager on a pediatric

floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing the developmental theory?

a. describes that stress is inevitable

B. emphasizes that change with one member affects the entire family

C. Provides guidance to assist families adapting to stress

d. defines consistencies in how families change

2. a nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. the nurse hears one parent state, “my son knows he better do what i say.” Which of the following parenting styles is the parent exhibiting?

a. authoritarian

B. Permissive

C. authoritative

d. Passive

3. a nurse is performing family assessment. Which of the following should the nurse include? (select all that apply.)

a. medical history

B. Parents’ education level

C. Child’s physical growth

d. support systems

e. stressors

PRACTICE Active Learning Scenario

a nurse is providing anticipatory guidance to the mother of a toddler. the nurse learns that the household includes the mother, toddler, an older brother, and a grandmother. use the ati active learning template: Basic Concept to complete this item.

RELATED CONTENT: describe the composition of this family.

UNDERLYING PRINCIPLES ● describe two methods the parent can use to positively influence the child. ● describe two ways the parent can promote acceptable behavior in the child.

NURSING INTERVENTIONS: include two additional family assessments the nurse should perform.

6 CHAPTER 1 Family-Centered nursing Care CONTENT MASTERY SERIES

Application Exercises Key 1. a. the family stress theory describes that stress is inevitable.

B. the family systems theory emphasizes that change with one member affects the entire family.

C. the family stress theory provides guidance to assist families adapting to stress.

d. CORRECT: the nurse should include that the developmental theory defines consistencies in how families change.

NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

2. a. CORRECT: this parent is exhibiting an authoritarian parenting style. the parent controls the adolescent’s behaviors and attitudes through unquestioned rules and expectations.

B. this parent is not exhibiting a permissive parenting style. using this style, the parent exerts little or no control over the adolescent’s behaviors, and consults the adolescent when making decisions.

C. this parent is not exhibiting an authoritative parenting style. using this style, the parent directs the adolescent’s behavior by setting rules and explaining the reason for each rule setting.

d. this parent is not exhibiting a passive parenting style. using this style, the parent is uninvolved, indifferent, and emotionally removed.

NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

3. a. CORRECT: the nurse should include a medical history on the parents, siblings, and grandparents when performing a family assessment.

B. CORRECT: the nurse should include the family structure, which includes family members, family size, roles/position within the family, and occupation and education of family members, when performing a family assessment.

C. the nurse should include the child’s physical growth when performing an individual assessment on the child.

d. CORRECT: the nurse should include support systems to determine the availability of extended family, work and peer relationships, and social systems and community resources to assist the family in meeting needs when performing a family assessment.

e. CORRECT: the nurse should include stressors, both expected and unexpected, when performing a family assessment.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

PRACTICE Answer

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT: this is an extended family, which includes at least one parent, one or more children, and other individuals who are either related or not related.

UNDERLYING PRINCIPLES ● Positive parental influences

◯ Have good mental health. ◯ maintain structure and routine in the household. ◯ engage in activities with the child. ◯ Validate the child’s feelings when communicating. ◯ monitor for safety concerns with special consideration for the child’s developmental needs.

● Promoting acceptable behavior ◯ Validate the child’s feelings, and offer sympathetic explanations. ◯ Provide role modeling and reinforcement for acceptable behavior. ◯ set clear and realistic limits and expectations based on the child’s developmental level.

◯ Focus on the behavior when implementing discipline.

NURSING INTERVENTIONS: Family assessments ● medical history on parents, siblings, and grandparents ● Family structure for roles/position within the family, as well as occupation and education of family members

● developmental tasks a family works on as the child grows ● Family characteristics, such as cultural, religious, and economic influences on behavior, attitudes, and actions

● Family stressors, such as expected (birth of a child) and unexpected (illness of a child, divorce, disability or death of a family member) events that cause stress

● availability of and family interactions with community resources ● Family support systems, such as availability of extended family; work and peer relationships; and social systems and community resources to assist the family in meeting needs or adapting to a stressor

NCLEX® Connection: Health Promotion and Maintenance, Aging Process

RN NURSING CARE OF CHILDREN CHAPTER 2 Physical assessment Findings 7

UNIT 1 FOUNDATIONS OF NURSING CARE OF CHILDREN SECTION: PERSPECTIVES OF NURSING CARE OF CHILDREN

CHAPTER 2 Physical Assessment Findings

alter exams to accommodate chronological age and developmental needs. involve children and family members in examinations. Praise children for cooperation during exams.

Observe for behaviors such as interacting with nurse, making eye contact, permitting physical touch, and willingly sitting on the examination table to determine the child’s readiness to cooperate.

language, cognition, and fine and gross motor development can be screened using a standardized tool such as the denver developmental screening test – Revised (denver ii). a combination of data collected from psychosocial and medical histories and a physical examination is used to determine need and make a referral for further evaluation.

NURSING CONSIDERATIONS ● Keep the room warm and well lit. ● Perform examinations in nonthreatening environments.

Keep medical equipment out of sight. ● Provide privacy. Determine whether older school-age

children and adolescents prefer a caregiver to remain during examination.

● Take time to play and develop rapport prior to beginning an examination.

● Observe for behaviors that demonstrate child’s readiness to cooperate, such as interacting with nurse, making eye contact permitting physical touch, and willingly sitting on the examination table.

● Explain each step of the examination to the child. ◯ Use age-appropriate language. ◯ Demonstrate what will happen using dolls, puppets, or paper drawings.

◯ Allow the child manipulate and handle equipment. ◯ Encourage the child to use equipment on others.

● Examine the child in a secure, comfortable position. For example, a toddler may sit on a parent’s lap if desired.

● Proceed to examine the child in an organized sequence when possible.

● If the child is uncooperative, assess reasons, be firm and direct about expected behavior, complete the assessment quickly, and use a calm voice.

● Encourage the child and family to ask questions during physical exams. Discuss findings with family after the examination.

PHYSIOLOGIC AND GROWTH MEASUREMENTS

temPeRatURe

2.1 Temperature by age EXPECTED LEVEL RECOMMENDED ROUTES

3 MONTHS 37.5˚ c (99.5˚ F) ● axillary

● Rectal (if exact measurement necessary)

6 MONTHS 1 YEAR 37.7˚ c (99.9˚ F)

3 YEARS 37.2˚ c (99.0˚ F) ● axillary ● tympanic ● Oral (if child cooperative) ● Rectal (if exact measurement necessary)5 YEARS 37.0˚ c (98.6˚ F)

7 YEARS 36.8˚ c (98.2˚ F) ● Oral ● axillary ● tympanic

9 YEARS 36.7˚ c (98.1˚ F)

11 YEARS 13 YEARS 36.6˚ c (97.9˚ F)

PUlse Rate Newborn: 80 to 180/min (depending on activity)

1 week to 3 months: 80 to 220/min (depending on activity)

3 months to 2 years: 70 to 150/min (depending on activity)

2 to 10 years: 60 to 110/min (depending on activity)

10 years and older: 50 to 90/min (depending on activity)

ResPiRatiOns Newborn to 1 year: 30 to 35/min

1 to 2 years: 25 to 30/min

2 to 6 years: 21 to 25/min

6 to 12 years: 19 to 21/min

12 years and older: 16 to 19/min

BlOOd PRessURe ● Readings should be compared with standard

measurements (National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents).

● Age, height, and gender all influence blood pressure readings. (2.2)

CHAPTER 2

8 CHAPTER 2 Physical assessment Findings CONTENT MASTERY SERIES

gROWth Growth can be evaluated using weight, length/height, body mass index (BMI), and head circumference. Growth charts are tools that can be used to assess the overall health of a child.

● It is recommended to use the World Health Organizations (WHO) growth standards for infants and children ages 0 to 2 in the United States and CDC growth charts for children 2 years and older.

● To see growth charts by age and gender, visit the website for the Centers for Disease Control and Prevention (http://www.cdc.gov/growthcharts)

EXPECTED PHYSICAL ASSESSMENT FINDINGS

geneRal aPPeaRance ● Appears undistressed, clean, well-kept, and without

body odors. ● Muscle tone: Erect head posture is expected in infants

after 4 months of age. ● Makes eye contact when addressed (except infants). ● Follows simple commands as age-appropriate. ● Uses speech, language, and motor skills spontaneously.

sKin, haiR, and nails

Skin ● Variations in skin color are expected based on race

and ethnicity. ● Temperature should be warm or slightly cool to

the touch. ● Skin texture should be smooth and slightly dry, not oily. ● Skin turgor exhibits brisk elasticity with

adequate hydration. ● Lesions are not expected findings. ● Skin folds should be symmetric.

Hair and scalp ● Hair should be evenly distributed, smooth, and strong.

◯ Manifestations of nutritional deficiencies include hair that is stringy, dull, brittle, and dry.

◯ Hair loss or balding spots on infants can indicate the child is spending too much time in the same position.

● Scalp should be clean and absent from any scaliness, infestations, and trauma.

● Assess children approaching adolescence for the presence of secondary hair growth.

Nails ● Pink over the nail bed and white at the tips ● Smooth and firm (but slightly flexible in infants)

lymPh nOdes Lymph nodes should be nonpalpable. Lymph nodes that are small, palpable, nontender, and mobile can be an expected finding in children.

head and necK

Head ● The shape of the head should be symmetric. ● Fontanels should be flat. The posterior fontanel usually

closes by 6 and 8 weeks of age, and the anterior fontanel usually closes between 12 and 18 months of age.

Face ● Symmetric appearance and movement ● Proportional features

Neck ● Short in infants ● No palpable masses ● Midline trachea ● Full range of motion present whether assessed actively

or passively

2.2 Expected blood pressure ranges by age and gender

Infants Girls Boys SYSTOLIC (mm Hg)

DIASTOLIC (mm Hg)

SYSTOLIC (mm Hg)

DIASTOLIC (mm Hg)

SYSTOLIC (mm Hg)

DIASTOLIC (mm Hg)

65 to 78 41 to 52 1 YEAR 83 to 114 38 to 67 80 to 114 34 to 66

3 YEARS 86 to 117 47 to 76 86 to 120 44 to 75

6 YEARS 91 to 122 54 to 83 91 to 125 53 to 84

10 YEARS 98 to 129 59 to 88 97 to 130 58 to 90

16 YEARS 108 to 138 64 to 93 111 to 145 63 to 94

RN NURSING CARE OF CHILDREN CHAPTER 2 Physical assessment Findings 9

eyes Eyebrows should be symmetric and evenly distributed from the inner to the outer canthus.

Eyelids should close completely and open to allow the lower border and most of the upper portion of the iris to be seen.

Eyelashes should curve outward and be evenly distributed with no inflammation around any of the hair follicles.

Conjunctiva ● Palpebral is pink. ● Bulbar is transparent.

Lacrimal apparatus is without excessive tearing, redness, or discharge.

Sclera should be white.

Corneas should be clear.

Pupils should be ● Round ● Equal in size ● Reactive to light ● Accommodating

Irises should be round with the permanent color manifesting around 6 to 12 months of age.

Visual acuity ● Can be difficult to assess in children younger than 3

years of age. ● Visual acuity in infants can be assessed by holding an

object in front of the eyes and checking to see whether the infant is able to fix on the object and follow it.

● Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers.

● Older children should be tested using a Snellen chart or symbol chart.

Peripheral visual fields should be ● Upward 50° ● Downward 70° ● Nasally 60° ● Temporally 90°

Extraocular movements ● Might not be symmetric in newborns. ● Corneal light reflex should be symmetric. ● Cover/uncover test should demonstrate equal movement

of the eyes. ● Six cardinal fields of gaze should demonstrate

no nystagmus.

Color vision ● Should be assessed using the Ishihara color test or the

Hardy-Rand-Rittler test. ● The child should be able to correctly identify shapes,

symbols, or numbers.

Internal exam ● Red reflex should be present in infants. ● Arteries, veins, optic discs, and maculae can be

visualized in older children and adolescents.

eaRs Alignment: The top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye.

External ear ● The external ear should be free of lesions and nontender. ● The ear canal should be free of foreign bodies

or discharge. ● Cerumen is an expected finding.

Internal ear ● In infants and toddlers, pull the pinna down and back to

visualize the tympanic membrane. ● In children older than 3 years of age, pull the pinna up

and back to visualize. ● The ear canal should be pink with fine hairs. ● The tympanic membrane should be pearly pink, or gray. ● The light reflex should be visible. ● Umbo (tip of the malleolus) and manubrium (long

process or handle) are the bony landmarks that should be visible.

Hearing ● Newborns should have intact acoustic blink reflexes to

sudden sounds. ● Infants should turn toward sounds. ● Older children can be screened by whispering a word

from behind to see whether they can identify the word.

nOse ● The position should be midline. ● Patency should be present for each nostril without

excessive flaring. ● Smell can be assessed in older children.

Internal structures ● The septum is midline and intact. ● The mucosa is deep pink and moist with no discharge.

mOUth and thROat Lips

● Darker pigmented than facial skin ● Smooth, soft, moist, and symmetric

Gums ● Coral pink ● Tight against the teeth

Mucous membranes ● Without lesions ● Moist, pink, smooth, and glistening

Tongue ● Infants can have white coatings on their tongues from

milk that can be easily removed. Oral candidiasis coating is not easily removed.

● Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips.

Teeth ● Infants should have six to eight teeth by 1 year of age. ● Children and adolescents should have teeth that are

white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth.

10 CHAPTER 2 Physical assessment Findings CONTENT MASTERY SERIES

Hard and soft palates: Intact, firm, and concave

Uvula: Intact and moves with vocalization

Tonsils ● Infants: Might not be able to visualize ● Children: Barely visible to prominent, same color as

surrounding mucosa,

Speech ● Infants: Strong cry ● Children and adolescents: Clear and articulate

thORaX and lUngs Chest shape

● Infants: Shape is almost circular with anteroposterior diameter equaling the transverse or lateral diameter.

● Children and adolescents: The transverse diameter to anteroposterior diameter changes to 2:1.

Ribs and sternum: More soft and flexible in infants; symmetric and smooth, with no protrusions or bulges

Movement ● Symmetric, no retractions ● Infants: Irregular rhythms are common. ● Children younger than 7 : More abdominal movement is

seen during respirations.

Breath sounds ● Inspiration is longer and louder than expiration ● Vesicular, or soft, swishing sounds, are heard over most

of the lungs

Breasts ● Newborns: Breasts can be enlarged during the first

few days. ● Children and adolescents: Nipples and areolas are darker

pigmented and symmetric. ◯ Females: Breasts typically develop between 10 to 14 years of age. The breasts should appear asymmetric, have no masses, and be palpable.

◯ Males can develop gynecomastia, which is unilateral or bilateral breast enlargement that occurs during puberty.

ciRcUlatORy system A comprehensive assessment of the circulatory system includes assessment of pulses, capillary refill time, neck veins, clubbing of fingers, peripheral cyanosis, edema, blood pressure, and respiratory status.

Heart sounds ● Auscultation should be done in both a sitting and

reclining position. ● S1 and S2 heart sounds should be clear and crisp. S1 is

louder at the apex of the heart. S2 is louder near the base of the heart. Physiologic splitting of S2 and S3 heart sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common.

Pulses ● Infants: Brachial, temporal, and femoral pulses should

be palpable, full, and localized. ● Children and adolescents: Pulse locations and expected

findings are the same as those in adults.

2.3 Infant reflexes

EXPECTED FINDING EXPECTED AGE

SUCKING AND ROOTING REFLEXES

elicited by stroking an infant’s cheek or the edge of an infant’s mouth the infant turns her head toward the side that is touched and starts to suck.

Birth to 4 months

PALMAR GRASP elicited by placing an object in an infant’s palm the infant grasps the object.

Birth to 3 months

PLANTAR GRASP elicited by touching the sole of an infant’s foot the infant’s toes curl downward.

Birth to 8 months

MORO REFLEX

elicited by allowing the head and trunk of an infant in a semi‑sitting position to fall backward to an angle of at least 30° the infant’s arms and legs symmetrically extend, then abduct while fingers spread to form c shape.

Birth to 4 months

STARTLE REFLEX elicited by clapping hands or by a loud noise the newborn abducts arms at the elbows, and the hands remain clenched.

Birth to 4 months

TONIC NECK REFLEX (FENCER POSITION)

elicited by turning an infant’s head to one side the infant extends the arm and leg on that side and flexes the arm and leg on the opposite side.

Birth to 3 to 4 months

BABINSKI REFLEX elicited by stroking the outer edge of the sole of an infant’s foot up toward the toes the infant’s toes fan upward and out.

Birth to 1 year

STEPPING elicited by holding an infant upright with his feet touching a flat surface the infant makes stepping movements.

Birth to 4 weeks

RN NURSING CARE OF CHILDREN CHAPTER 2 Physical assessment Findings 11

Abdomen ● Without tenderness, no guarding. Peristaltic waves can

be visible in thinner children. ● Shape: Symmetric and without protrusions around the

umbilicus ◯ Infants and toddlers have rounded abdomens. ◯ Children and adolescents should have flat abdomens.

● Bowel sounds should be heard every 5 to 30 seconds.

genitalia Anus: Surrounding skin should be intact with sphincter tightening noted if the anus is touched. Routine rectal exams are not done with the pediatric population.

MALE: Hair distribution is diamond shaped after puberty in adolescent males. No pubic hair is noted in infants and small children.

● Penis ◯ Penis should appear straight. ◯ Urethral meatus should be at the tip of the penis. ◯ Foreskin might not be retractable in infants and small children.

◯ Enlargement of the penis occurs during adolescence. ◯ The penis can look abnormally small in males who are obese because of skin folds partially covering the base.

● Scrotum ◯ The scrotum hangs separately from the penis. ◯ The skin on the scrotum has a rugose appearance and is loose.

◯ The left testicle hangs slighter lower than the right. ◯ The inguinal canal should be absent of swelling. ◯ During puberty, the testes and scrotum enlarge with darker scrotal skin.

FEMALE: Hair distribution over the mons pubis should be documented in terms of amount and location during puberty. Hair should appear in an inverted triangle. No pubic hair should be noted in infants or small children.

● Labia: Symmetric, without lesions, moist on the inner aspects

● Clitoris: Small, without bruising or edema ● Urethral meatus: Slit-like in appearance with no

discharge ● Vaginal orifice: The hymen can be absent, or it can

completely or partially cover the vaginal opening prior to sexual intercourse.

mUscUlOsKeletal system Length, position, and size of extremities are symmetric.

Joints

Stable and symmetric with full range of motion and no crepitus or redness

Spine

Infants: Spines should be without dimples or tufts of hair. They should be midline with an overall C-shaped lateral curve.

Toddlers appear squat with short legs and protuberant abdomens.

Preschoolers appear more erect than toddlers.

Children should develop the cervical, thoracic, and lumbar curvatures like that of adults.

Adolescents should remain midline (no scoliosis noted).

2.4 Cranial nerves: expected findings

INFANTS CHILDREN AND ADOLESCENTS I OLFACTORY difficult to test identifies smells through each nostril individually

II OPTIC looks at face and tracks with eyes has intact visual acuity, peripheral vision, and color vision

III OCULOMOTOR Blinks in response to light has pupils that are reactive to light

has no nystagmus and PeRRla is intact

IV TROCHLEAR looks at face and tracks with eyes has the ability to look down and in with eyes

V TRIGEMINAL has rooting and sucking reflexes is able to clench teeth together detects touch on face with eyes closed

VI ABDUCENS looks at face and tracks with eyes is able to see laterally with eyes

VII FACIAL has symmetric facial movements has the ability to differentiate between salty and sweet on tongue has symmetric facial movements

VIII ACOUSTIC tracks a sound Blinks in response to a loud noise

does not experience vertigo has intact hearing

IX GLOSSOPHARYNGEAL has an intact gag reflex has an intact gag reflex is able to taste sour sensations on back of tongue

X VAGUS has no difficulties swallowing speech clear, no difficulties swallowing Uvula is midline

XI SPINAL ACCESSORY moves shoulders symmetrically has equal strength of shoulder shrug against examiner’s hands

XII HYPOGLOSSAL has no difficulties swallowing Opens mouth when nares are occluded

has a tongue that is midline is able to move tongue in all directions with equal strength against tongue blade resistance

12 CHAPTER 2 Physical assessment Findings CONTENT MASTERY SERIES

Gait

Toddlers and young children: A bowlegged or knock-knee appearance is a common finding. Feet should face forward while walking.

Older children and adolescents: A steady gait should be noted with even wear on the soles of shoes.

neUROlOgic system

Infant reflexes (2.3)

Cranial nerves (2.4)

Deep tendon reflexes

Deep tendon reflexes should demonstrate the following. ● Partial flexion of the lower arm at the biceps tendon ● Partial extension of the lower arm at the triceps tendon ● Partial extension of the lower leg at the patellar tendon ● Plantar flexion of the foot at the Achilles tendon

Cerebellar function (children and adolescents)

Finger to nose test: Rapid coordinated movements

Heel to shin test: Able to run the heel of one foot down the shin of the other leg while standing

Romberg test: Able to stand with slight swaying while eyes are closed

RN NURSING CARE OF CHILDREN CHAPTER 2 Physical assessment Findings 13

Application Exercises 1. a nurse is preparing to assess a

preschool‑age child. Which of the following is an appropriate action by the nurse to prepare the child?

a. allow the child to role‑play using miniature equipment.

B. Use medical terminology to describe what will happen.

c. separate the child from her parent during the examination.

d. Keep medical equipment visible to the child.

2. a nurse is checking the vital signs of a 3‑year‑old child during a well‑child visit. Which of the following findings should the nurse report to the provider?

a. temperature 37.2˚ c (99.0˚ F)

B. heart rate 106/min

c. Respirations 30/min

d. Blood pressure 88/54 mm hg

3. a nurse is assessing a child’s ears. Which of the following is an expected finding?

a. light reflex is located at the 2 o’clock position.

B. tympanic membrane is red in color.

c. Bony landmarks are not visible.

d. cerumen is present bilaterally.

4. a nurse is assessing a 6‑month‑old infant. Which of the following reflexes should the infant exhibit?

a. moro

B. Plantar grasp

c. stepping

d. tonic neck

5. a nurse is performing a neurological assessment on an adolescent. Which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? (select all that apply.)

a. clenching teeth together tightly

B. Recognizing sour tastes on the back of the tongue

c. identifying smells through each nostril

d. detecting facial touches with eyes closed

e. looking down and in with the eyes

PRACTICE Active Learning Scenario

a nurse is preparing to examine a preschool‑age child. Use the ati active learning template: Basic concept to complete this item.

UNDERLYING PRINCIPLES: describe two behaviors that indicate the child is ready to cooperate.

NURSING INTERVENTIONS ● describe two actions to take if child is uncooperative. ● include three actions to promote the child’s comfort during the examination.

14 CHAPTER 2 Physical assessment Findings CONTENT MASTERY SERIES

Application Exercises Key 1. a. CORRECT: the nurse should allow the child to role‑play

or manipulate actual or miniature equipment to reduce anxiety and fear related to the examination.

B. the nurse should use neutral words and avoid overestimating the child’s understanding of words when describing what will happen.

c. the nurse should encourage parental presence during the examination.

d. the nurse should keep medical equipment out of sight unless showing or using it on the child.

NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

2. a. a temperature of 37.2˚ c (99.0˚ F) is within the expected reference range for a 3‑year‑old child and should not be reported to the provider.

B. a heart rate of 106/min is within the expected reference range for a 3‑year‑old child and should not be reported to the provider.

c. CORRECT: Respirations of 30/min is above the expected reference range for a 3‑year‑old child and should be reported to the provider.

d. a blood pressure of 90/52 mm hg is within the expected reference range for a 3‑year‑old child and should not be reported to the provider.

NCLEX® Connection: Management of Care, Collaboration with Interdisciplinary Team

3. a. the light reflex should be located around the 5 or 7 o’clock position.

B. the tympanic membrane should be a pearly pink, or gray color.

c. Bony landmarks should be visible.

d. CORRECT: the presence of cerumen bilaterally is an expected finding.

NCLEX® Connection: Reduction of Risk Potential, Potential for Alterations in Body Systems

4. a. the moro reflex is exhibited by infants from birth to the age of 4 months.

B. CORRECT: the plantar grasp is exhibited by infants from birth to the age of 8 months.

c. the stepping reflex is exhibited by infants from birth to the age of 4 weeks.

d. the tonic neck reflex is exhibited by infants from birth to the age of 3 to 4 months.

NCLEX® Connection: Health Promotion and Maintenance, Developmental Stages and Transitions

5. a. CORRECT: clenching teeth together tightly is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve.

B. Recognizing sour tastes on the back of the tongue is an appropriate reaction by the adolescent when checking the glossopharyngeal cranial nerve.

c. identifying smells through each nostril is an appropriate reaction by the adolescent when checking the olfactory cranial nerve.

d. CORRECT: detecting facial touches with eyes closed is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve.

e. looking down and in with the eyes is an appropriate reaction by the adolescent when checking the trochlear cranial nerve.

NCLEX® Connection: Reduction of Risk Potential, System Specific Assessments

PRACTICE Answer

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES ● child is ready to cooperate. ● interacting with nurse. ● making eye contact. ● Permitting physical touch. ● Willingly sitting on examination table.

● accepting and handling equipment.