6-year-old child.

Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.

Brudzinski's and Kernig's signs are positive.

Vital Signs.

Respiratory rate 28/min.

Pulse rate 120/min.

BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.

Vancomycin 300 mg IV q 6 hr following blood cultures.

Acetaminophen 240 mg PO q 6 hr PRN fever.

A nurse is planning care for a child during admission to the facility.

Which of the following actions should the nurse take first?

The correct answer is choiceA. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice.The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended.The balloon should only be inflated once the catheter is correctly positioned in the bladder.

Choice A rationale:

Improved short-term memory. Donepezil is a medication used to treat Alzheimer's disease and other forms of dementia. It works by increasing the levels of certain chemicals in the brain that are involved in memory, thinking, and reasoning. Therefore, improved short-term memory is an indication that the medication is effective, as it suggests enhanced cognitive function in the client.

Choice B rationale:

Enhanced mood. While improved mood can be a positive outcome of treating dementia, it is not the primary goal of donepezil therapy. The main focus is on cognitive improvement, particularly in memory and thinking skills. Enhanced mood alone may not be a reliable indicator of the medication's effectiveness in this context.

Choice C rationale:

Can perform ADLs independently. The ability to perform activities of daily living (ADLs) independently is an important aspect of a patient's overall well-being. However, this improvement may not solely be attributed to the effects of donepezil. Other factors, such as rehabilitation or support services, can also contribute to the patient's ability to perform ADLs. While it is a positive outcome, it is not a specific indication of donepezil's effectiveness.

Choice D rationale:

Increased food intake. Increased food intake is not a direct effect of donepezil. Donepezil does not have a primary role in regulating appetite or food intake. Therefore, this finding is not a reliable indicator of the medication's effectiveness in treating dementia.