A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

Establish a new routine for the child to follow while in the facility.

Use medical terminology when discussing procedures with the child.

Encourage the child to play with toys such as a pounding board.

Perform the morning assessments when the parent is not in the room.

Answer and Explanation

The Correct Answer is C

A. Establish a new routine for the child to follow while in the facility. This is incorrect because preschoolers find comfort in familiar routines. Maintaining their usual routines as much as possible helps reduce anxiety.
B. Use medical terminology when discussing procedures with the child. This is incorrect because preschoolers have a limited understanding of medical terms. Using simple, age-appropriate language helps them better comprehend what is happening.
C. Encourage the child to play with toys such as a pounding board. This is correct because preschoolers benefit from play to express emotions and relieve stress. Toys like a pounding board allow them to release frustration in a safe and developmentally appropriate way.
D. Perform the morning assessments when the parent is not in the room. This is incorrect because having a parent present provides comfort and security, which can help the child remain calm during assessments.

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Correct Answer is D

Explanation

A. Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia.
B. Seeing dark spots is not a common or expected outcome. Some clients may experience temporary blurriness, but not dark spots.
C. Bruising of the eyelids is not a typical side effect of cataract removal. There may be mild swelling or redness, but significant bruising is unusual.
D. Cataract removal involves removing the cloudy lens and replacing it with an artificial intraocular lens (IOL) to restore clear vision. This statement shows the client understands the procedure.

A. Remind the AP about maintaining client confidentiality. B. Notify the client of the breach of confidentiality. C. Notify the ethics committee of the breach of confidentiality. D. File an incident report with the risk management department.

Correct Answer is A

Explanation

A. Reminding the AP about confidentiality is the appropriate immediate response. The nurse should provide education and reinforce HIPAA regulations to prevent future breaches.
B. Notifying the client is unnecessary and could cause undue distress. The priority is to address the behavior and prevent further violations.
C. Notifying the ethics committee is excessive for a first-time or minor violation. This step may be necessary if breaches continue despite education.
D. Filing an incident report is not required unless the breach has significant consequences. The best first step is direct education.

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A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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