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 D
Explanation
A. Basketball. Basketball is a high-impact sport with a risk of falls and collisions, which could lead to bleeding episodes in a child with hemophilia.
B. Soccer. Soccer involves physical contact and a high risk of injury, making it unsafe for children with hemophilia.
C. Gymnastics. Gymnastics carries a risk of falls, bruising, and joint injuries, which can lead to internal bleeding.
D. Bowling. Bowling is a low-impact sport with minimal risk of injury, making it a safe option for children with hemophilia.
Correct Answer is A
Explanation
A. "Wear a face mask when working within 3 feet of a child who is infected." Influenza spreads through droplets, so wearing a face mask within 3 feet of an infected child helps prevent transmission.
B. "Administer antibacterial medication within 24 hr of the onset of symptoms." Influenza is caused by a virus, not bacteria, so antibacterial medications (antibiotics) are not effective. Antiviral medications (e.g., oseltamivir) may be given within 48 hours of symptom onset.
C. "Children should be considered infectious for 14 days after the onset of symptoms." . Children with influenza are most contagious 1 day before symptoms appear and up to 5 to 7 days after onset.
D. "Administer the influenza vaccine every 6 months." The influenza vaccine is given annually (once per year), not every 6 months.
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