A nurse is caring for a patient with a chest tube connected to wall suction due to a right-sided pneumothorax. The patient reports a sensation of chest burning.
What should the nurse do next?

Choice A rationale

Recording that the nurse was unable to take the patient’s temperature would not be the most appropriate action in this situation. The nurse can wait for a certain period of time and then take the patient’s temperature.

Choice B rationale

Continuing to take the oral temperature immediately after the patient has consumed ice chips could result in an inaccurately low temperature reading. The cold from the ice chips can temporarily lower the temperature in the mouth.

Choice C rationale

Waiting for 30 minutes and then returning to take the oral temperature is the most appropriate action. Consuming cold substances can lower the oral temperature temporarily, so it’s recommended to wait 15-30 minutes after the patient has consumed something cold before taking an oral temperature.

Choice D rationale

Giving the patient a sip of warm water, waiting for 5 minutes, and then taking the temperature is not the standard procedure. While it might help to normalize the temperature in the mouth more quickly, it’s generally recommended to wait at least 15-30 minutes after the patient has consumed something cold before taking an oral temperature.

The correct answer is Choice D

Choice A rationale: Moral reasoning, including distinguishing right from wrong, requires abstract cognitive processing and internalization of social norms, typically emerging during the concrete operational stage around age 7. Toddlers are in Piaget’s sensorimotor to early preoperational phase, where egocentrism dominates and behavior is guided by immediate consequences rather than ethical principles. They lack the neurological maturity and social-cognitive integration required for moral discourse, making this milestone developmentally inappropriate for the toddler age group.

Choice B rationale: Performing simple chores involves task comprehension, motor coordination, and social cooperation, which are more consistently observed in preschool-aged children (4–5 years). Toddlers may imitate adult actions but lack sustained attention, impulse control, and fine motor precision needed for chore completion. Their psychosocial development is centered on autonomy and exploration, not structured responsibility. Expecting chore cooperation at this stage exceeds normative developmental expectations and may lead to frustration or behavioral resistance.

Choice C rationale: Printing letters and numbers requires advanced fine motor control, visual-motor integration, and symbolic cognition, typically achieved between ages 5 and 6. Toddlers are still developing basic hand-eye coordination and may engage in scribbling, but they lack the neuromuscular refinement and cognitive mapping needed for structured writing. Neurodevelopmental milestones do not support this skill in the toddler phase, making it scientifically inaccurate to expect printing behavior before preschool age.

Choice D rationale: By age 3, toddlers begin to tolerate brief separations from primary caregivers due to improved object permanence, emotional regulation, and social awareness. This aligns with Erikson’s autonomy vs. shame and doubt stage, where toddlers explore independence while maintaining secure attachment. Separation anxiety peaks around 9–18 months and typically declines by age 3. The ability to separate easily for short periods reflects healthy psychosocial development and is a scientifically appropriate expectation for toddlers.