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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should give your child's last daily dose of the medication before 6 o'clock in the evening." Methylphenidate is a stimulant, and giving it too late in the day can cause insomnia. Administering the last dose before 6 PM helps minimize sleep disturbances.
B. "You will need to give your child the medication after meals." Methylphenidate is typically given before meals to enhance its absorption and effectiveness. Taking it after meals is not recommended as it can delay absorption.
C. "You will need to have your child's blood glucose level checked monthly." There is no need for regular blood glucose monitoring unless the child has other conditions like diabetes. Methylphenidate does not typically affect blood glucose levels.
D. "You should not give your child the medication on weekends." Continuous use of methylphenidate is generally recommended to provide consistent symptom control, including on weekends. “Drug holidays” may be considered in specific cases but should be discussed with a healthcare provider.
Correct Answer is B
Explanation
A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.
B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.
C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.
D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.
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