A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths?
"This will not be painful, just a little uncomfortable."
"Let's play a game of blowing cotton balls across your table."
"Do you want to take deep breaths for me now?"
"You can't go to the playroom until you finish doing your deep breathing."
The Correct Answer is B
A. "This will not be painful, just a little uncomfortable." While this statement might provide some reassurance, it does not actively engage the child or make the task of taking deep breaths more enjoyable.
B. "Let's play a game of blowing cotton balls across your table." This is the best choice as it makes deep breathing fun and engaging for the child, encouraging them to participate without feeling like it’s a chore.
C. "Do you want to take deep breaths for me now?" This approach is too passive and doesn't engage the child actively or make the activity interesting.
D. "You can't go to the playroom until you finish doing your deep breathing." This approach can create negative reinforcement and might make the child associate deep breathing with punishment or coercion, which is not desirable.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Low-pitched cry: A high-pitched cry, not a low-pitched one, is more typical of increased ICP in infants. A low-pitched cry is not a common sign of ICP and may be more related to other conditions.
B. Positive Babinski reflex: The Babinski reflex is normal in infants up to about 1 year of age and is not indicative of increased ICP. It is a normal finding and not specific to increased intracranial pressure.
C. Insomnia: Infants with increased ICP may exhibit irritability and changes in sleeping patterns, but insomnia (difficulty sleeping) is not a classic symptom. The focus should be on other more specific signs like changes in cry and physical appearance.
D. Bulging fontanel: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude. This is a classic symptom of increased intracranial pressure in infants.
Correct Answer is D
Explanation
A. New onset of seizure disorder in the child's sibling: This does not contraindicate DTaP vaccination unless the child itself has a history of seizures or neurological disorders.
B. Evidence of sensitivity to egg antigens: DTaP vaccine is not contraindicated by egg allergy; this is more relevant to influenza vaccines.
C. Afebrile otitis media: This is not a contraindication for DTaP vaccination.
D. Temperature of 40.5° C (104.9° F) after last DTaP: A high fever following a previous dose of DTaP may indicate a severe reaction, necessitating caution or further evaluation before administering another dose.
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