A nurse is performing a physical assessment for a 13-year-old adolescent. Which of the following actions should the nurse take?
Have the child bend forward at the waist and check for asymmetry of the scapula.
Auscultate the abdomen for at least 1 min if bowel sounds are absent.
Use the FACES scale to assess pain.
Observe abdominal movement to determine the respiratory rate.
The Correct Answer is A
A. "Have the child bend forward at the waist and check for asymmetry of the scapula." This maneuver is known as the Adam's forward bend test and is used to screen for scoliosis, which commonly appears during adolescence.
B. "Auscultate the abdomen for at least 1 min if bowel sounds are absent." If bowel sounds are absent, the nurse should listen for at least 5 minutes in each quadrant before concluding they are truly absent.
C. "Use the FACES scale to assess pain." The FACES scale is typically used for younger children (3-7 years old). Adolescents can usually use a numeric rating scale (0-10) for pain assessment.
D. "Observe abdominal movement to determine the respiratory rate." Abdominal breathing is characteristic of infants and younger children. In adolescents, the nurse should observe chest movement to assess respiratory rate.
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Related Questions
Correct Answer is C
Explanation
A. "Ask her if she is ready to eat her sandwich for lunch." Asking if the child is ready to eat might increase resistance, as toddlers often assert their autonomy by saying "no." This does not provide an option that would allow the toddler to make a choice.
B. "Ask her if she would like to have her favorite sandwich for lunch." This is a yes/no question which might lead to refusal, especially if the child is already in a stage of negativism, where they are more likely to resist being told what to do.
C. "Tell her that she may have a sandwich or soup for lunch." Offering choices between two acceptable options gives the toddler a sense of control, which can help reduce oppositional behavior. This approach aligns with the developmental stage of toddlers who are asserting independence.
D. "Tell her she is having her favorite sandwich for lunch." Telling the child what they will have to eat might lead to resistance. Providing a choice rather than making a statement gives the child more agency in their decision-making.
Correct Answer is D
Explanation
A. "Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.
B. "Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.
C. "Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.
D. "Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.
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