Patient Scenario, Chapter 34, Child Health Assessment
A TODDLER WHO IS LIGHT IN WEIGHT
Joey Diller is a 15-month-old toddler you see in an ambulatory care setting.
CHIEF CONCERN:
“Everyone says he seems short.”
HISTORY OF CHIEF CONCERN:
The infant weighed 9 lb 6 oz at birth. The mother was told he was “doing well” at 2, 4, and 6
month health checkups. The father lost job at that time so family has had no health insurance
since then so the child has received no further health maintenance care. The mother feels he has
not grown or gained weight during last 6 months.
FAMILY PROFILE:
The family is intact. The father currently receives unemployment compensation. The mother
works as assistant in florist shop. Both parents have associate college degrees. The family lives
in second floor, two-bedroom apartment over flower shop. Finances is rated as “not good”
because of large car payment and high monthly rent.
PREGNANCY HISTORY:
This is the first pregnancy for a 24-year-old mother. The mother had “slight” elevation of
glucose during pregnancy; she was followed closely by obstetrician, but no therapy initiated.
Birth was at 40 weeks; infant breathed spontaneously. The parents were delighted with healthy
boy.
HISTORY OF PAST ILLNESSES:
Joey had “occasional” colds; he had no major illnesses or hospitalizations. He had no poisonings
or emergency room visits.
DAY HISTORY:
Nutrition: Infant breastfed for 3 months until mother returned to work. He took Similac with iron
for 3 months and then changed to whole milk at 6 months; 2% milk at 12 months.
Currently, he takes 16 oz milk daily by bottle, about 6 oz by glass. He eats table food.
Typical day:
Breakfast: Scrambled eggs with cheese, 1 tbsp
Lunch: Pieces of baloney and cheese, chunks of watermelon
Dinner: ½ toasted cheese sandwich, chunks of canned pears
Snacks: 1 pretzel, 1 cracker, few pieces popcorn
Sleep: He sleeps 10 hours at night and has 2-hour nap in afternoon.
Play: He enjoys pull toys and toy telephones.
Growth & development: He sat at 7 months; he walked at 12 months. He says “Mama go” and
Speedy come” (dog’s name).
REVIEW OF SYSTEMS:
Skin: Occasional diaper rash; he fell on porch steps yesterday and received “brush burn” on
forehead
GI: Bowel movements: two daily, yellow and “baby-like”; voiding frequently
PHYSICAL EXAMINATION:
Height: 80 cm (50%); weight: 11 kg (50%); head circumference: 47 cm (50%)
General appearance: Small but well-proportioned and active 15-month-old Caucasian male
Head: Normocephalic; fontanelles closed; abrasion 1 cm × 1 cm on forehead
Eyes: Red reflex present; follows to six cardinal fields of gaze
Ears: TMs pink; light reflex present; slight cerumen
Nose: Midline septum; no discharge; membrane pink
Mouth: 18 teeth; no cavities; palate intact; tonsillar tissue enlarged but not reddened; midline
uvula
Neck: Full range of motion; one shotty node in left anterior cervical chain; midline trachea
Chest: Lungs clear to auscultation; respiratory rate: 20 breaths/min
Heart: Rate: 96 beats/min; grade 1 systolic murmur at left fourth intercostal space; marked
physiologic splitting
Abdomen: Soft; no masses
Genitalia: Normal male; testes descended
Extremities: Slight genu valgum (bow legs); walks with wide placed toddler gait; full range of
motion; one ecchymotic lesion 1½ cm over left tibia; no clubbing of fingers
Neurologic: Responsive; motor and sensory function grossly intact
Joey is assessed as a toddler with normal growth and development.
STUDY QUESTIONS:
1. To begin interviewing Joey’s mother about his growth and development, how should you open
the interview?
a. “Joey is gaining weight well, isn’t he?”
b. “Do you have any concerns about Joey?”
c. “Does Joey ever cough or sneeze?”
d. “Tell me about Joey.”
Answer: b. Questions that are open-ended but sufficiently specific yield the best results. Stating
that he is gaining weight is leading and asking about coughing and sneezing is too specific.
2. You will begin your health assessment with a review of systems. During a health history, a
review of systems can have what benefit?
a. Inform the parent what illnesses are most common.
b. Help a parent remember any illness a child has had.
c. Emphasize the importance of safety.
d. Educate the child and parents about the chief concern.
Answer: b. A review of systems can stir the memory of parents and reveal illness information.
3. If Joey were apprehensive about being examined, what technique would be most appropriate?
a. Begin the exam with him in his mother’s lap.
b. Explain that nothing you will do will hurt him.
c. Tell Joey that health exams are very important.
d. Ask Joey to tell you if something scares him.
Answer: a. Children feel most comfortable with their parent, so allow a child to beginning an
exam with the child comfortably seated in a parent’s lap can reduce anxiety. This child is likely
too young to have his expectations set.
4. Children younger than 2 years of age generally have their head circumference measured as a
routine part of health assessment. From where should you make this measurement?
a. The center of the child’s forehead to the base of the occiput
b. The middle of the forehead through the parietal prominences
c. Just above the level of the eyes and then just above the ears
d. Above the eyebrows through the prominent part of the occiput
Answer: d. A head circumference measuring tape should pass across the middle of the forehead
and the most prominent point of the rear of the head.
5. To assess if a child has a strabismus, you would use a cover test. During this assessment, you
will do which of the following?
a. Cover Joey’s head with a drape and ask him to pull it off.
b. Cover an eye and inspect for movement when the cover is removed.
c. Touch each of Joey’s eyes with a cotton wisp to see if he winces.
d. Assess if Joey can look up and down and to the right and the left.
Answer: b. A cover test detects if an eye is not well aligned by observing it after it has been
temporarily covered. This can reveal the presence of strabismus.
6. You assess Joey for normal ear alignment. In preparation for this assessment, you should be
aware that the upper aspect of the ear pinna is:
a. Slightly lower than the level of the tip of the nose.
b. On a line from the inner to outer canthus of his eyes.
c. Opposite a line drawn from the corner of the mouth.
d. Opposite the lowest crease on his forehead or eyebrows.
Answer: b. The average position for the top of the ear pinna is on a line drawn from the inner to
the outer canthus of the eye.
7. You assess Joey’s mouth and document the fact that he has a geographic tongue. How should
this finding be best interpreted?
a. His tongue is rough appearing and uneven.
b. His tongue is swollen and tender to touch.
c. His tongue has ulcers along the medial borders.
d. He does not have full range of motion in his tongue.
Answer: a. A geographic tongue refers to a common finding in children where the surface of
their tongue is uneven and rough appearing.
8. When you assess Joey’s cardiovascular system and note he has physiologic splitting. This
means:
a. Joey’s heartbeat sounds far away or under water.
b. His second heart sound is split when Joey inhales.
c. The first heart sound is absent when Joey talks.
d. You cannot tell the first from the second sound.
Answer: b. Physiologic splitting is an extra heart sound caused by late closure of the pulmonary
valve on inspiration.
9. You are assessing Joey’s abdomen. To assess if Joey’s liver is enlarged, what technique would
you use?
a. Percuss the entire abdomen for a hollow sound.
b. Measure Joey’s abdominal girth and compare it to age-based norms.
c. Auscultate his abdomen for increased bowel sounds.
d. Palpate the abdomen below Joey’s right rib cage.
Answer: d. An enlarged liver will be palpable below the right rib cage.
10. When Joey reaches adolescence, you would want to teach him how to do a self-testicular
exam. A precaution that you would include in this would be:
a. Examining will cause sharp pain but is important.
b. He shouldn’t do this more than every 3 months.
c. One testis is usually slightly lower than the other.
d. If he discovers a cord-like streak, this is abnormal.
Answer: c. One testis is normally slightly lower than the other. A cord-like streak is most likely
the vas deferens.
11. Joey has a “shotty,” or pea-sized, swelling in one anterior cervical chain lymph node. What is
the etiology of this assessment finding?
a. A common reaction to teething
b. A recent respiratory infection
c. An effect of birth trauma
d. An allergy to milk products
Answer: b. Swollen lymph nodes often occur from a recent respiratory infection. Teething
should not cause this.
12. You inspect Joey’s fingers to see if they are “clubbed.” The presence of clubbed fingers
should prompt you to suspect which of the following health problems?
a. Respiratory disorders
b. Enlarged livers or spleens
c. Gastrointestinal disorders
d. Many neurologic diseases
Answer: a. Respiratory disorders cause lack of oxygen so extra capillaries form in fingertips
making them appear broad and “clubbed.”
13. You are assessing Joey’s head currently focusing on his ears. To assess Joey’s tympanic
membrane, you would pull the pinna of his ear:
a. Down and back
b. Down and forward
c. Up and back
d. Up and forward
Answer: a. To straighten the ear canal in a child younger than 2 years, pull the ear pinna down
and back. In older children, the movement would be up and back.
14. To assess Joey’s abdomen, you should begin with what assessment technique?
a. Palpation
b. Percussion
c. Inspection
d. Auscultation
Answer: c. Health assessment usually begins with inspection. Auscultate the abdomen before
palpating or percussing, or else bowel sounds will be suppressed.
15. Vision of older children, when tested by a Snellen eye chart, is recorded as two numbers such
as 20/20 or 2/30. The first of these numbers represents:
a. The distance the child stands from the chart.
b. The optical depth of a normal child’s eye.
c. The distance a child is able to see clearly.
d. A designated Snellen chart conversion factor
Answer: a. The first number is the distance the child stands from the chart or 20 ft.
16. When doing health assessments, for which child would it be most important to do screening
for color discrimination?
a. A 6-year-old girl who refuses to play sports
b. A 16-year-old boy who dislikes school
c. A 2-year-old girl who cannot name colors
d. An infant who has pale blue eyes
Answer: b. Color discrimination abnormalities (color blindness) occur most frequently in boys.
Two-year-olds cannot normally name colors. Children with blue eyes are not more prone to this
problem.
17. Suppose you discover a school-age child has a two line difference in vision acuity (20/20 in
right eye; 20/50 in the left). What would be your best action?
a. Advise his parents this was probably caused by a birth injury.
b. Assure the parents many children have this much difference.
c. Refer the child to his health care provider because this can be amblyopia.
d. Ask the child if he has noticed any difficulty reading small print.
Answer: c. Amblyopia or loss of central vision may be present if there is over a two line
deviation in vision.
18. You learn that another practitioner has administered a Denver Developmental II Test to Joey.
Which of the following statements would be the best introduction to this test for his mother?
a. The test will identify different development skills.
b. It will be best if you do not watch Joey during the test.
c. The test is an important screen for children’s intelligence.
d. The test may be inaccurate because it is not well standardized.
Answer: a. Denver developmental tests measure developmental milestones. It is not an IQ test
and is well standardized.
19. A Goodenough-Harris Drawing Test is an assessment instrument that is comparatively easy
to administer with children. How is this test administered?
a. Asking a child to identify/name body parts
b. Seeing if the child can repeat words after you
c. Observing if a child can color between lines
d. Asking a child to draw a picture of a person
Answer: d. A Goodenough-Harris Drawing Test is a simple test of IQ that requires a child to
draw a picture of a person. The number of body parts drawn is compared to a standard scoring
scale.
20. You assess a child’s hearing using a Rinne test. To do this, you would:
a. Hold a tuning fork against the middle of the child’s forehead.
b. Measure the distance across the room a child can hear a tuning fork.
c. Hold a tuning fork in back of and then in front of the ear being tested.
d. Press a ringing tuning fork against the child’s cheek as he is speaking.
Answer: c. Because air conducted sound is heard better than bone conducted sound, the usual
child will hear the tuning fork when it is held in front of the ear better than when it is held
against the back of the ear.
OPEN-ENDED QUESTIONS:
21. What if Joey, at 15 months, is very resistant to being examined. What techniques would you
use to help this toddler adjust better to a physical examination?
Answer: Allowing a 2-year-old to get acquainted with the examiner before the exam is helpful.
Allowing the child to sit in a parent’s lap, playing a game with the light of the otoscope, drawing
a face on a tongue blade, etc. are all games that can make an examination less frightening.
22. What if Joey’s mother tells she’s lost Joey’s immunization record so has no idea what
immunizations Joey has received. She’s sure he’s never received a full series of anything. Should
Joey have everything repeated?
Answer: Because many families are so mobile today, this is a common situation. As a rule,
immunization series are not completely started over; they are picked up at the point most
practical (if this mother knew her child had vaccines at 2 months, e.g., the child would start with
4-month vaccines such as DTaP and IPV). An important nursing intervention is to be certain
parents receive a record of their child’s immunizations, with an explanation of what the
immunization was and that this is important information for parents to know and keep.
FILL IN THE BLANK QUESTIONS:
23. Determining the characteristic of a body part by listening to the sound you hear when you
strike it with your finger is termed _________.
Answer: percussion
24. Bowel sounds can be heard in _________ abdominal quadrants.
Answer: four
MULTIPLE RESPONSE QUESTION:
25. Which of the following sections are usually included in a child’s health assessment
interview? (Select all that apply.)
a. Review of systems
b. Family history
c. Past medical history
d. Chief concern
Answer: a, b, c, d
CORRECT ORDER QUESTION:
26. What order of the following techniques would be best to use when assessing a child’s
abdomen?
a. Percussion
b. Palpation
c. Inspection
d. Auscultation
Answer: c, d, b, a