Author Question: The nurse is preparing care for a preschool-age child scheduled for a health history and physical ... (Read 77 times)

Kthamas · **on:** Jun 27, 2018

The nurse is preparing care for a preschool-age child scheduled for a health history and physical assessment. At which point will the nurse determine nursing diagnosis appropriate for the child's care?

A) Prior to the assessment
B) At the time of assessment
C) After completing the review of systems
D) After specific problems have been identified

Question 2

Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?

A) Plantar grasp
B) Step
C) Babinski
D) Neck righting

1_Step_At_ATime · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

B
Feedback:
Nursing diagnosis related to health assessment most commonly address a health concern identified at the time of the assessment. When establishing nursing diagnoses, do not overlook diagnoses that accentuate the healthy functioning of a child and family, even when diagnoses that address specific problems have been identified. Wellness diagnoses are crucial components of the entire assessment picture. The nurse cannot identify diagnoses before the assessment occurs.

Answer to Question 2

B
Feedback:
Appropriate appearance and disappearance of primitive reflexes, along with the development of protective reflexes, indicates a healthy neurologic system. The step reflex is a primitive reflex that appears at birth and disappears at 4 to 8 weeks of age. The plantar grasp reflex is a primitive reflex that appears at birth and disappears at about the age of 9 months. The Babinski reflex is a primitive reflex that appears at birth and disappears around the age of 12 months. The neck righting reflex is a protective reflex that appears around the age of 4 to 6 months and persists.