The nurse gathering physical assessment data on an infant will ...

[tingc95]

The nurse gathering physical assessment data on an infant will often find it best to begin the assessment with examination of:
 
  1. Head, hair, and scalp.
  2. Ears, nose, and throat.
  3. Musculoskeletal function.
  4. Heart and lung sounds.

Question 2

The nurse is caring for a client diagnosed with a glioblastoma who has just returned from surgery to remove as much of the tumor as possible.
 
  When gathering data on this client, the nurse's priority will be to monitor which of the following? Select all that apply. Standard Text: Select all that apply. 1. Ability to respond to commands and bilateral muscle strength
  2. Ability to speak, write, and recognize objects
  3. Orientation to time, place, and person
  4. Pupil response to light
  5. Coping mechanism

[lindahyatt42]

Answer to Question 1

4
Rationale: Heart sounds can be impossible to hear if the infant is crying or fussy, so the initial assessment should start with auscultating heart and lung sounds while the child is quiet. Undressing the child to examine the musculoskeletal function or inserting an otoscope into the ear usually will cause the child to cry. Palpating the head and scalp risks making the infant cry as well, although the risk is lower.

Answer to Question 2

1,2,3,4
Rationale: Location of the tumor, and areas of potential damage within the brain, will determine specific assessment requirements, but in general, the nurse will monitor the client's ability to respond to commands (touch your nose with your left hand, blink your eyes, etc.); bilateral muscle strength; ability to speak, write, and recognize objects; pupil response; and orientation. Any alteration in neurological activity should be reported to the nursing supervisor or surgeon immediately. Coping mechanisms are not a priority, and will not be evaluated until the client has time to recover from the immediate postoperative period.