A nurse is assessing the head of an 18-month-old girl. During the assessment, the nurse should do which of the following to make sure that the child has adequate skull and brain growth?
1. Check the circumference and document the findings on the growth chart
2. Check the suture lines and posterior fontanel for alignment
3. Measure the head circumference, assess the anterior fontanel, and document the findings on the growth chart
4. Check the child's eye tracking with a pen light
3
Feedback
1. Assessment of the anterior fontanel is also needed for an accurate assessment of brain and skull growth.
2. The anterior fontanel should be aligned at this age. Head circumference will indicate adequate nutrition.
3. Assessment of the circumference and suture lines in the anterior fontanel will indicate if suture lines have fused.
4. The tracking of the pen light only allows for a minimal assessment.
You might also like to view...
A female client develops a fungal vaginal infection after being treated with antibiotics for strep throat. Which of the following components of the epidemiological triangle is primarily responsible?
a. Agent b. Environment c. Host d. Interaction of agent and environment
The nurse is providing discharge instructions to a renal transplant recipient. The patient has a follow-up appointment the next day for routine post-transplant laboratory bloodwork, including trough levels of anti-rejection medications
Which instruction describes what the patient should do regarding the anti-rejection medications the next day? a. "Take your morning dose of medications at midnight with sips of water." b. "Take your morning dose of medications after labs have been drawn." c. "Skip your morning dose of medications and then resume your evening doses." d. "Hold all doses of your medications the day you have labs drawn."
An anti-bullying program is being launched in the community by a multidisciplinary team. The community health nurse has been asked to help facilitate a conversation about factors that are associated with being a bully. Identify the factors
A. Parents/caregivers with lower educational levels B. Small stature C. Good academic standing D. Age E. ADHD (Attention Deficit and Hyperactivity Disorder) 1. A, C, D, E 2. A and D 3. A, B, D 4. A, B, D, E
Clocks and calendars are of no value in reality orientation.
Answer the following statement true (T) or false (F)