A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child'stemperature, which method would be least appropriate?

Tympanic

Oral

Axillary

Rectal

Answer and Explanation

The Correct Answer is D

A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.

B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the

thermometer in their mouth.

C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic

measurements or when rectal measurement is contraindicated.

D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.

However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.

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Correct Answer is A

Explanation

A. Appearance of pubic hair around 11 to 13 years old - Pubic hair development typically occurs around the ages of 11 to 13 in girls, signaling the onset of puberty. This is a normal part of physical development.

B. Swelling or redness of the labia minora - Swelling or redness of the labia minora may indicate inflammation or infection, unrelated to normal puberty development.

C. Lesions on the external genitalia - Lesions on the external genitalia are not normal signs of puberty and may indicate a medical issue requiring evaluation and treatment.

D. Presence of labial adhesions - Labial adhesions, where the labia minora stick together, are not directly related to puberty onset and may require medical attention if they cause discomfort or urinary issues

A. Auscultation B. Deep palpation C. Inspection D. Superficial palpation

Correct Answer is C,A,D,B

Explanation

Correct Answer:C, A, D, B.

C. Inspection:The initial step in an abdominal assessment is to inspect the abdomen visually. This allows the nurse to observe for any abnormalities in skin color, shape, and

movement without causing discomfort or altering findings that could be affected by palpation or auscultation.

A. Auscultation:Following inspection, auscultation is performed before any palpation. This is because palpation can stimulate bowel sounds, which may alter the nurse's ability to accurately assess the bowel activity and vascular sounds.

D. Superficial palpation:After auscultation, superficial palpation is done to detect tenderness, distension, or superficial masses. It is gentle and less likely to cause discomfort or alter deeper structures.

B. Deep palpation: The final step is deep palpation, which is used to examine the organs and structures that are deeper within the abdominal cavity. It is performed last to prevent any potential discomfort or alteration in the patient's condition that could interfere with the earlier steps of the assessment.

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A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child'stemperature, which method would be least appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty?

Correct Answer is A

Explanation

A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,A,D,B

Explanation

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