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.

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

Use medical terminology when discussing procedures with the child.

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

Answer and Explanation

The Correct Answer is B

A. Establish a new routine for the child to follow while in the facility. - Preschoolers thrive on routines and familiarity, especially in unfamiliar environments like acute care facilities. Therefore, it's essential for the nurse to maintain the child's existing routine as much as possible to provide a sense of security and stability.
B. Encourage the child to play with toys such as a pounding board. - Encouraging play with age-appropriate toys helps promote normalcy, reduce anxiety, and facilitate coping for preschoolers during their hospital stay. Toys like a pounding board provide opportunities for physical activity and engagement, which can help distract and entertain the child.
C. Use medical terminology when discussing procedures with the child. - Preschoolers have limited understanding of complex medical terminology. Using simple, age-appropriate language helps the child better comprehend what is happening, reducing fear and anxiety. Therefore, it's important for the nurse to avoid medical jargon and use language the child can understand.
D. Perform the morning assessments when the parent is not in the room. - Preschoolers often feel more comfortable and secure when their parents are present, especially in unfamiliar environments like hospitals. Performing assessments in the presence of the parent helps maintain the child's sense of security and allows the parent to participate in the child's care and provide comfort and support.

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Correct Answer is B

Explanation

A. Hepatitis A - Hepatitis A vaccine is typically administered in two doses, with the first dose given at 12-23 months of age. It is not routinely given at 2 months of age.
B. Rotavirus - Rotavirus vaccine is recommended for administration at 2 months of age, with subsequent doses given at 4 and 6 months. It helps protect against rotavirus infection, a common cause of severe diarrhea in infants and young children.
C. Influenza - Influenza vaccine is usually not administered until 6 months of age. Infants younger than 6 months are considered too young to receive the influenza vaccine.
D. Varicella - Varicella (chickenpox) vaccine is typically given in two doses, with the first dose recommended at 12-15 months of age. It is not routinely administered at 2 months of age.

A. Abdominal distention B. Watery stool C. Dizziness D. Oliguria

Correct Answer is A

Explanation

A. Abdominal distention: Abdominal distention is a classic sign of paralytic ileus, which is a temporary cessation of intestinal peristalsis. When peristalsis is impaired, gas and fluid accumulate in the intestines, leading to abdominal distention.
B. Watery stool: Watery stool is not typically associated with paralytic ileus. In paralytic ileus, bowel movements are usually absent or significantly reduced due to decreased or absent peristalsis, resulting in constipation rather than watery stool.
C. Dizziness: Dizziness is not a typical sign of paralytic ileus. While the underlying cause of paralytic ileus may lead to electrolyte imbalances, which can manifest as dizziness, it is not a direct symptom of paralytic ileus itself.
D. Oliguria: Oliguria, or decreased urine output, is not directly related to paralytic ileus. Paralytic ileus affects the gastrointestinal tract, leading to symptoms such as abdominal distention and constipation, but it does not directly affect urinary output.

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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?

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