Nursing Assessment Techniques

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Questions and Answers

What is the primary purpose of measuring the apical pulse in infants and children under 2-3 years?

To count the pulse rate per one minute (correct)

To assess blood pressure

To evaluate skin temperature

To measure oxygen saturation

Which equipment is essential for measuring the apical pulse?

Glucometer

Sphygmomanometer

Thermometer

Stethoscope (correct)

What should be done first before measuring the apical pulse?

Prepare the equipment

Verify the correct child

Explain the procedure

Wash hands (correct)

Which of the following environments is suitable for measuring the pulse?

In a calm environment Signup and view all the answers

What is NOT a characteristic assessed when measuring the pulse?

Height Signup and view all the answers

What should be done after removing the thermometer from the mouth?

Wipe it from up to down. Signup and view all the answers

How long should the thermometer remain in place when measuring temperature orally?

3 minutes. Signup and view all the answers

What should you do with the thermometer before taking a reading?

Rotate it until the mercury column is visible. Signup and view all the answers

What is the first step in the axillary temperature measurement procedure?

Rinse and dry the axilla. Signup and view all the answers

Which item is not necessary when measuring body temperature axillary method?

Digital thermometer. Signup and view all the answers

What should be done with the thermometer after use?

Wash it with soap and water. Signup and view all the answers

What is required to ensure during axillary temperature measurement?

Ensure contact between the skin of the arm and skin of the chest. Signup and view all the answers

Which equipment is not listed for measuring body temperature?

Stethoscope. Signup and view all the answers

What is the optimal position for a child during the procedure?

Side-lying position with hips flexed Signup and view all the answers

How far should a rectal thermometer be inserted for children?

2.5 cm (1 inch) Signup and view all the answers

What action should be taken if resistance is felt while inserting the thermometer?

Stop the insertion immediately Signup and view all the answers

Which step is NOT part of the procedure after taking the temperature?

Store the thermometer in a drawer Signup and view all the answers

What should be done to the anal area before starting the temperature measurement?

Rinse and dry the anal area Signup and view all the answers

How long should the thermometer remain inserted during the procedure?

1 minute Signup and view all the answers

What is the recommended way to hold the thermometer before reading?

At eye level Signup and view all the answers

What method should be used to wipe the thermometer after use?

From up to down the bulb Signup and view all the answers

What is the first step after completing the procedure?

Wipe the earpieces and diaphragm with alcohol Signup and view all the answers

What equipment is essential for assessing the radial pulse?

Watch with a second hand Signup and view all the answers

Which step involves ensuring the correct patient is being assessed?

Verify the correct child by using two identifiers Signup and view all the answers

During the procedure, where should you place your fingers to assess the radial pulse?

On the radial side of the inner wrist Signup and view all the answers

What should you do after returning used equipment?

Wash hands Signup and view all the answers

What step comes before assessing pulse rate and quality?

Assess for risk factors Signup and view all the answers

What is the primary reason for wiping the earpieces and diaphragm with alcohol?

To prevent cross-contamination Signup and view all the answers

What is an important consideration before beginning the pulse assessment?

Assessing for risk factors for alterations in radial pulse Signup and view all the answers

When should an apical heart rate be assessed in children?

When the child is younger than 2 years of age Signup and view all the answers

What should be done to prepare the stethoscope before assessment?

Wipe earpieces and diaphragm with alcohol swab Signup and view all the answers

What is an appropriate action to help a child relax during the procedure?

Help the child to relax as much as possible Signup and view all the answers

Where should the diaphragm of the stethoscope be placed to assess the apical heart rate?

Between the fourth and fifth intercostal spaces just below the nipple Signup and view all the answers

How should the apical rate be counted if it is irregular?

Count for 60 seconds Signup and view all the answers

Why is it important to assess for risk factors for alterations in apical pulse?

To identify potential issues with heart rhythm Signup and view all the answers

What indicates that a child is on a digitalis preparation?

There is a risk of toxicity that can cause arrhythmias Signup and view all the answers

What sounds should be auscultated for during the apical heart rate assessment?

Normal S1 and S2 heart sounds (heard as 'lub-dub') Signup and view all the answers

Study Notes

Measuring Body Temperature

Axillary Method: Place the bulb of the thermometer in the apex of the axilla, ensuring contact between the skin of the arm and skin of the chest.
Rectal Method: Place the child in the side-lying position with the hips flexed, or in the prone or supine position. Insert a well-lubricated rectal thermometer through the anal sphincter into the rectum for one minute, a maximum of 2.5 cm for children and 1.5 cm for infants.

Measuring Apical Pulse

Equipment: Watch, stethoscope, alcohol swab.
Procedure: Place the diaphragm of the stethoscope between the fourth and fifth intercostals spaces just below the nipple. Auscultate for normal S1 and S2 heart sounds (heard as "lub-dub").
Counting: Count the rate for 30 seconds and multiply by 2 if the rate is regular. If the rate is irregular, or if the child is younger than 2 years of age or receiving cardiovascular medication, count for a full minute (60 seconds).

Measuring Radial Pulse

Equipment: Watch with a second hand.
Procedure: Place the tips of the first two or middle three fingers over the groove along the radial side of the child's inner wrist.

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Description

This quiz covers the essential techniques for measuring body temperature and apical pulse in children. Students will learn various methods for accurate readings and the importance of each technique in clinical practice. Test your understanding of these fundamental nursing skills.