Health Promotion and Maintenance
99. A clinic nurse prepares to perform a physical assessment on a preschool child. What are the appropriate actions for the nurse to take when preparing for and performing the examination? Prioritize the nurse's actions by placing each correct step in sequential order.
. Allow child to keep underpants on.
. Allow child to undress in private.
. Ask child's preference for parental involvement.
. Inspect ears, eyes, and mouth.
. Proceed in head-to-toe direction.
. Gain cooperation with bright objects as a distraction.
Test-Taking Tip
Because preschool children's central task is initiative vs. guilt, they benefit from interventions that offer independence in decision making.
Content Area: Child Health, Growth and Development; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Health Promotion and Maintenance/Developmental Stages and Transitions
Health Promotion and Maintenance
. . . .
Answer 1 is correct because the preschool child may feel more comfortable keeping underpants on during the assessment because a common fear of preschoolers is genital mutilation. Answer 2 is incorrect since it would be unsafe to leave a preschool child alone in an examination room to undress. This intervention would be appropriate for an adolescent. Answer 3 is correct because the nurse should first ask the child if the parents should participate in the procedure. The child should be given options for parent participation, such as whether parents should be present, if the child would like help undressing, and if the child would prefer to sit on the parent's lap or sit alone on the examination table. Answer 4 is correct because, although the nurse proceeds in a head-to-toe direction, inspecting eyes, ears, and mouth is invasive and is best performed at the end of the assessment in order to not disrupt the rest of the examination. Answer 5 is correct because the nurse should proceed in a head-to-toe direction while keeping the most invasive assessments for the end. Answer 6 is incorrect because this technique is appropriate for infants, not preschoolers.