A nurse is assessing the fontanels of an 8-month-old infant. Which of the following findings should the nurse recognize as an expected finding

The correct answer is d. Evaluate functioning of the suction device.

Choice D rationale:

• Prompt assessment of the suction device is crucial to determine if it's functioning properly.If the suction is inadequate,it can lead to gastric contents accumulating and potentially causing vomiting.
• Assessing the suction device first allows for timely interventionif it's not working correctly,preventing further complications and discomfort for the client.

Choice A rationale:

• Replacing the NG tube might be necessary if it's dislodged or blocked, but it shouldn't be the immediate action.
• Evaluating the suction device first can help determine if the NG tube itself is the issue or if the problem lies with the suction.

Choice B rationale:

• Providing oral hygiene care is important for comfort and to prevent aspiration, but it's not the priority intervention in this situation.
• Addressing the cause of the vomiting, which could be related to suction malfunction, takes precedence.

Choice C rationale:

• Administering an antiemetic might be helpful to control nausea and vomiting, but it doesn't address the underlying cause.
• Evaluating the suction device first is essential to ensure proper gastric decompression and prevent further vomiting episodes.

Tell the client, “You seem to be very upset.”.

This is an example of a therapeutic communication technique that validates the client’s feelings and encourages them to express their emotions verbally rather than physically. It also shows empathy and respect for the client’s perspective.

Choice A is wrong because engaging the panic alarm is not the first action to take when interacting with an agitated client.

The nurse should first try to calm the client down by using verbal and nonverbal communication skills, such as maintaining eye contact, speaking in a calm and clear voice, and avoiding sudden movements or gestures.

Engaging the panic alarm should be done only if the client becomes violent or poses a threat to themselves or others.

Choice B is wrong because using a face shield with a mask when providing care to the client is not relevant to the situation.

This is a personal protective equipment (PPE) that is used to prevent exposure to infectious agents or body fluids, not to manage agitation.

Using a face shield with a mask may also increase the client’s anxiety or paranoia, as they may perceive it as a sign of hostility or fear.

Choice D is wrong because initiating seclusion protocol is not appropriate for a client who is agitated, pacing, and speaking loudly.

Seclusion is a restrictive intervention that involves isolating the client in a locked room to prevent harm to themselves or others.

It should be used only as a last resort when less restrictive measures have failed or are contraindicated, and only with a provider’s order and close monitoring.

Secluding an agitated client may escalate their behavior and violate their rights.

Normal ranges for agitation are not applicable, as agitation is not a quantifiable parameter.

However, some tools that can be used to assess agitation include the Richmond AgitationSedation Scale (RASS), which ranges from -5 (unarousable) to +4 (combative), and the Agitated Behavior Scale (ABS), which ranges from 14 (no agitation) to 56 (severe agitation).