A nurse is caring for a 4-year-old child who is admitted to the hospital for pneumonia. The nurse observes that the child is restless, agitated, and frequently tries to get out of bed. What is the most appropriate nursing intervention to prevent falls in this child?
Apply a vest restraint to the child and secure it to the bed frame.
Place a bed alarm on the child's mattress and lower the bed rails.
Move the child to a room closer to the nurses' station and check on him frequently.
Involve the child in diversionary activities and encourage parental supervision.
The Correct Answer is D
Choice A reason: This is not the appropriate nursing intervention, as it may increase the risk of injury, agitation, or psychological trauma in the child. Restraints should only be used as a last resort and with a physician's order.
Choice B reason: This is not the appropriate nursing intervention, as it may not prevent the child from falling out of bed or wandering around the unit. Bed alarms are useful for alerting the staff, but they do not stop the child from moving.
Choice C reason: This is a possible nursing intervention, as it may facilitate closer observation and monitoring of the child. However, it may not address the underlying cause of the child's restlessness or agitation.
Choice D reason: This is the most appropriate nursing intervention, as it may reduce the child's boredom, anxiety, or fear and provide a sense of security and comfort. Diversionary activities may include toys, games, books, or music that are suitable for the child's age and developmental level. Parental supervision may also help prevent falls by assisting the child with toileting, positioning, or ambulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not the correct answer, as the malfunction is not the most common type of equipment-related injury for a child who has a CVC. Malfunctions may occur due to mechanical failure, occlusion, infection, or thrombosis of the CVC, but it can be prevented or detected by regular assessment and maintenance of the CVC.
Choice B reason: This is not the correct answer, as misuse is not the most common type of equipment-related injury for a child who has a CVC. Misuse may occur due to human error, lack of knowledge, or inappropriate use of the CVC, but it can be prevented or corrected by following the standard guidelines and policies for CVC care.
Choice C reason: This is the correct answer, as disconnection is the most common type of equipment-related injury for a child who has a CVC. Disconnection may occur due to accidental removal, breakage, or loosening of the CVC connections, and it can cause serious complications such as hemorrhage or air embolism. The nurse should secure the CVC connections with tape or clamps and monitor the child for signs of bleeding or air embolism, such as hypotension, tachycardia, dyspnea, chest pain, cyanosis, or altered mental status.
Choice D reason: This is not the correct answer, as entanglement is not the most common type of equipment-related injury for a child who has a CVC. Entanglement may occur due to excessive or tangled tubing that can interfere with the child's mobility or comfort, but it can be prevented or minimized by organizing the tubing and keeping it away from the child's reach and movement.
Correct Answer is B
Explanation
Choice A reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it does not describe the correct anatomical landmark for a lumbar puncture. The needle should be inserted between the fourth and fifth lumbar vertebrae, not the third and fourth, to avoid damaging the spinal cord.
Choice B reason: This statement by the nurse would indicate that the procedure is done correctly and safely, as it describes the correct position for a lumbar puncture. The lateral recumbent position with flexion of the spine helps expose the intervertebral spaces and facilitate the insertion of the needle.
Choice C reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the post-procedure care, not the procedure itself. Applying a sterile dressing and monitoring for signs of infection or bleeding are important steps to prevent complications after a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.
Choice D reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the pre-procedure and intra-procedure care, not the procedure itself. Giving pain medication and asking for pain or discomfort are important steps to reduce anxiety and discomfort during a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.
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