HESI Patient Review--Pediatrics-Chronic
Pediatric Health Problems (Austin Brown)
1. For each patient seen, your nursing assessment upon meeting the patient is usually brief.
This brief nursing assessment generally includes: (Select 5)
- the child's stature (length) and weight
- any allergies the child may have
- current medications being taken by the child
- the child's vital signs
- the child's and/or caregiver's knowledge of age-related safety issues
- the reason for the clinic visit - ANS -The child's stature (length) and weight
-Any allergies the child may have
-Current medications being taken by the child
-The child's vital signs
-The reason for the clinic visit
Stature (length) and weight are critical data that reflect how a child is growing. This information
is usually plotted on a clinical growth curve at each visit. Weight is important in determining
pediatric medication doses.
Assessment and written documentation of known allergies is essential to prevent administration
of medications or therapies that could cause an allergic and potentially life-threatening
condition.
Knowledge of current medications (prescribed and over-the-counter) is important if changes or
additions need to be made. This will also give you an indication of potential educational needs
related to medications.
Vital signs (temperature, pulse, respirations, and blood pressure) provide objective data that
reflect a child's overall health status. In the Pulmonary Clinic, all vital signs are important, but
special focus is placed on assessing respiratory function.
Childhood safety information is important, but can be reviewed later in the visit, as part of
routine patient teaching
It is especially important to determine from the patient (or his caregiver) the reason for the
current visit. The patient may be scheduled for a periodic routine "well-child" visit. The patient
may have come to the clinic because of specific complaints. The patient may be scheduled for a
follow-up visit, but is now sick, which may alter the plan of care.
2. You made the judgment that Austin's breathing is labored, based on a quick observation.
Which of the following, when observed in an infant, is a sign of labored breathing?
- Irregular rhythm of respirations
- Grunting with inspiration
- Foul breath odor
- Bloated abdomen
,- Cyanosis - ANS Grunting with inspiration
In general, noisy respirations are not considered normal and are associated with labored
breathing. Audible wheezing (musical whistling sound) occurs when airway passages are
narrowed due to constriction of air passages and/or mucous congestion. Grunting (deep guttural
sound) may also occur when breathing is labored, as a child struggles to obtain air.
Rhythm of respirations refers to regularity of rate. When rate is consistent, rhythm is regular.
When rate is not consistent, rhythm is irregular. Infants and young children often have irregular
respiratory rhythms, under normal circumstances. Therefore, irregularity of respiratory rhythm
would not necessarily indicate labored breathing, although it may be noted when breathing is
labored.
3. You take Austin and his parents to an exam room. Given your initial impression of Austin,
your next action should be to:
- call a pediatrician stat
- obtain a detailed history
- administer 100% oxygen by face mask
- obtain Austin's vital signs
- determine Austin's weight - ANS Obtain Austin's vital signs
All vital signs are important, and respiratory assessment is especially important with Austin. If
respiratory function is compromised, respiratory data will be abnormal. In addition, heart rate
and blood pressure may be affected.
4. Austin is crying and is in his mother's arms. Which approach is best as you plan your
assessment of Austin?
- Take Austin from his mother so he can get accustomed to you and your touch before you
begin your assessments
- Allow Austin to stay in his mother's arms as you begin your assessment - ANS Allow Austin to
stay in his mother's arms as you begin your assessment
A 6-month-old infant may fear strangers. Austin may become upset if you take him from his
mother. Also, crying can lead to increased work of breathing. Allowing Austin to stay in his
mother's arms would be the best approach to take as you begin your assessment.
5. Besides oxygen saturation and rhythm of respirations, respiratory function assessment
should include: (Select 5)
- respiratory rate
- heart rate
- mechanics of breathing
- capillary refill time
- breath sounds
- skin color
- chest rise and fall - ANS -Respiratory rate
, -Mechanics of breathing
-Breath sounds
-Skin color
-Chest rise and fall
Assessment of respiratory function should include respiratory rate. Tachypnea (rapid breathing)
is often the first indication of respiratory distress. A slow respiratory rate in an ill child is an
ominous sign.
The work associated with breathing should be noted when a respiratory assessment is done.
Respiratory mechanics are altered with respiratory distress. When breathing is normal, the soft
tissues between bony areas on the chest do not sink in. When the work of breathing is
increased, inspiratory chest retractions (intercostal, subcostal, and suprasternal) and nasal
flaring may be present. Head bobbing, grunting stridor, and prolonged exhalation are also signs
of significant respiratory distress and altered mechanics.
Auscultation of breath sounds is an important aspect of respiratory assessment. Breath sounds
should easily be heard bilaterally, and sounds should be the same on both sides. Any
adventitious (abnormal) sounds should be noted. Due to the smallness and thinness of a child's
chest wall, breath sounds are easily transmitted and referred, therefore pitch and intensity of
breath sounds should be assessed in all lung fields and determination made as to their equality.
Skin color and temperature are important aspects of respiratory assessment. In a warm
environment, a child's trunk and extremities should be the same color and temperature.
Hypoxemia can lead to mottled, pale, or dusky skin color, and extremities that are cool to touch.
Chest expansion, reflecting the depth of respirations, is an indication of tidal volume and
ventilation. Inadequate chest rise is a sign of inadequate tidal volume and ineffective ventilation,
which can result in hypoxemia and tissue hypoxia. Depth of respirations should be assessed wh
6. Given the respiratory data you have collected on Austin, you determine that Austin is:
- breathing normally for a child being seen in the Pulmonary Clinic
- having labored respirations, but not in acute distress
- in severe respiratory distress
- in imminent danger of respiratory arrest - ANS Having labored respirations, but not in acute
distress
Austin presents with several signs that reflect increased work of breathing (tachypnea,
retractions, nasal flaring, adventitious breath sounds, pale color), but he appears to be
compensating and is not in acute distress. However, he does require diligent monitoring.
7. Before weighing Austin, you determine his height (length) by measuring from his heels to the
top of his head as he lies supine.
- True
- False - ANS True
Austin's weight and height (length) will be plotted on a clinical growth chart (Birth to 36 months:
Boys) that uses recumbent length. Recumbent length is obtained by measuring from the infant's
