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. Ribbon Like, foul-smelling stools: Hirschsprung disease is characterized by a lack of nerve cells in parts of the colon, leading to obstruction and resulting in narrow, ribbon-like stools due to the passage through a narrowed section of bowel.
B. Chronic hunger: This is not typical for Hirschsprung disease. Children may actually have a poor appetite due to discomfort and constipation.
C. Projectile vomiting: Projectile vomiting is more commonly associated with pyloric stenosis, not Hirschsprung disease.
D. Rigid abdomen: While abdominal distention can occur due to severe constipation and fecal impaction, a rigid abdomen is more indicative of a more acute or severe abdominal condition, such as peritonitis or severe bowel obstruction.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}
Explanation
Place the infant in a knee-chest position: Indicated: ☑️
The knee-chest position is commonly used during a "tet spell," which involves episodes of cyanosis due to decreased oxygen levels. This position increases systemic vascular resistance, which helps redirect blood flow to the lungs, improving oxygenation.
Administer morphine via IV bolus: Indicated: ☑️
Morphine is used to calm the infant, reduce respiratory effort, and decrease pulmonary vascular resistance. It can help in reducing the severity of the tet spell by promoting better oxygenation.
Provide 100% oxygen by face mask: Indicated: ☑️
Administering 100% oxygen can help increase the amount of oxygen in the blood and reduce the effects of hypoxia. Oxygen is a vasodilator and can reduce pulmonary resistance, making it easier for the infant to oxygenate blood.
Request a prescription for a diuretic: Contraindicated: ☑️
Diuretics are generally not indicated in the acute management of tet spells. While they are used in conditions with fluid overload, their use in this context is not beneficial and could potentially worsen the infant's condition by causing dehydration and further reducing blood volume.
Perform nasopharyngeal suctioning for a maximum of 5 seconds: Contraindicated: ☑️
Nasopharyngeal suctioning can be stressful for the infant and may worsen cyanosis or provoke a tet spell due to increased agitation and respiratory effort. It's typically not recommended unless there's a clear indication for airway clearance.
Prepare to assist with the insertion of a chest tube: Contraindicated: ☑️
Chest tube insertion is not a treatment for tet spells or ToF. It is usually indicated for pneumothorax or significant pleural effusions, which are not related to the acute cyanotic episodes seen in ToF. Preparing for this procedure would be inappropriate in this scenario.
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