NCSN Review Section 3 & 4 with 100% correct answers 2024.

What are the steps of the nursing process ? Assessment - collect data Diagnosis - interpret data , make hypothesis Identify expected outcomes Planning Implementation Evaluation Follow - up What is the difference between subjective and objective data ? Subjective data - what the patient says Objective data - what is seen , heard , felt , smelled What are the standards of practice ? Agreed - upon level of practice developed by the profession with a goal to promote quality care Best practice Professional expectations They are NOT law . Define primary prevention and give an example . Promoting the health of all through interventions like promoting immunizations and health promotion behaviors ( proper nutrition , sleep , dental care , use of seat belts , bike helmets ) Define secondary prevention and give an an example . Identifying problems early to promote early intervention in those most at risk Example : screening high - risk groups In a health appraisal , how do you record the child's chief complaint ? In the child's own words How does heart rate change as a child ages ? Heart rate decreases from about 90-120 under age 8 to about 75-95 over age 15 . How does respiratory rate change as a child ages? Respiratory rate decreases from about 20-25 under age 7 to about 18-22 for over age 12 . How does blood pressure change as a child ages? Blood pressure increases from about 96/57 under age 7 to 110/65 for teens . What are the parameters for choosing an appropriate blood pressure cuff ? Width of the cuff should be 40% of arm circumference between elbow and shoulder It should cover 2/3-3/4 of upper arm Bladder cuff should cover >80% of arm circumference . An appropriate pain scale for a non verbal child is_____________. FLACC (Facial, legs, activity, cry, consolability) The most appropriate pain scale for a pre - schooler or young school - age child who does not understand rank order is_________________. FACES scale The FACES scale is a valid and reliable pain scale that allows for a child to describe the pain even though he / she does not understand rank order . What is the purpose of screening ? To identify the existence or extent of a particular problem and to access reliable interventions to prevent morbidity. Screening does not result in a diagnosis . When using stadiometer to measure height, measure to the nearest _______inch. 1/8th When using a scale to measure weight, measure to the nearest _______pound. 1/4 What are the normal parameters for body mass index for age? What are the normal parameters for overweight and obesity ? 5% - 85% is normal (BMI of 18.5- < 25) 85% - <95 for overweight (BMI 25 - 29.99) >95% for obesity (BMI ≥30) A drooping eyelid is called__________. Ptosis Pupil constriction of <2mm is called_____________. Miosis Pupils that are dilated >6mm is called ___________. Mydriasis The term for unequal pupils is __________. Aniscoria Vision matures at approximately _________ years of age 7 years Vision is the last sense to mature To assess near vision (farsightedness), how close should the vision chart be held ? 10-13 inches Name 3 valid and reliable vision charts . LEA Symbols Sloan or Snellen letters HOTV chart What is procedure for testing for nearsightedness ( myopia ) ? Nearsightednessis the inability to focus on distant objects > 10 feet away. The procedure is : Chart should be eye-level for child Have child stand behind 10-foot line Start with 20/40, then move to 20/20 line Pass if can read > half of the line Cover 1 eye ; keep both eyes open Test with glasses What are parameters for vision screening referral for further evaluation? ≤5 years 20/50 or 2 line difference ≥ 6 years 20/40 or 2 line difference What eye muscle tests measure for eye alignment ? Cover - uncover test Hirschberg Test Define Strabismus . Abnormal alignment of one eye Define nystagmus Involuntary jerky movements of the eyes What is the treatment for amblyopia ? Patch the healthy eye so that the affected eye muscle gets stronger . What test is used to detect color blindness ? Ishihara Color Test Plates Pseudoisochromatic Plates Hearing is mature at________. Birth One of the best indicators of a young child's hearing is____________ Development of speech according to normal developmental parameters. Toddlers who are babbling and not speaking words , should have their hearing tested . List the procedures for a hearing screen : Soundproof or very quiet room 1 table , 2 chairs , electrical outlet Child's chair 90 degree angle Audiometer Warm up Test both sides Remove earrings Calibrate annually Have child raise hand if hear sound Define decibels and what is normal hearing ? The loudness of sound. Normal speech is 50-70 decibels Usually hearing 20 decibels is acceptable Define Hertz and what is normal hearing? The pitch (high and low sounds) Usually test at 1000, 2000, and 4000 Hertz What is the school nurse's best course of action if a child does not pass the hearing screen? Recheck the child's hearing screen in 2-4 weeks. Sinuses develop through what developmental stage ? Adolescence