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 A

Explanation

A. Report sudden, persistent headaches: Sudden, persistent headaches can indicate a sickle cell crisis or complications such as stroke. Prompt reporting of these symptoms allows for timely intervention and management of potential complications.
B. Avoid meningococcal immunizations: Immunizations, including meningococcal vaccines, are essential for individuals with sickle cell anemia because they are at increased risk of infections, including those caused by encapsulated bacteria like Neisseria meningitidis. Immunizations help prevent serious infections and their complications.
C. Apply cold compresses to painful areas: Cold compresses are not recommended for individuals with sickle cell anemia. Heat therapy is typically used to alleviate pain associated with vaso-occlusive crises, which are common in sickle cell disease. Heat helps relax muscles and improve blood flow to the affected area, reducing pain and promoting healing.
D. Restrict fluid intake during times of stress: Individuals with sickle cell anemia should maintain adequate hydration at all times, especially during periods of stress or illness. Dehydration can exacerbate sickling of red blood cells and increase the risk of vaso-occlusive crises. Therefore, fluid intake should be encouraged, and restrictions should be avoided unless specifically advised by a healthcare provider.

A. Observe the client for 1 hr after meals. B. Obtain the client's vital signs every other day. C. Weigh the client every 48 hr. D. Allow the client to eat meals in their room.

Correct Answer is A

Explanation

Observe the client for 1 hr after meals: This action is appropriate during the first week of care for a client with anorexia nervosa to monitor for signs of refeeding syndrome, such as electrolyte imbalances or hypoglycemia, which can occur after meals. Continuous observation allows for prompt intervention if complications arise.
B. Obtain the client's vital signs every other day: Vital signs should be monitored more frequently, especially during the initial phase of care, to assess for any physiological changes associated with refeeding or complications of anorexia nervosa.
C. Weigh the client every 48 hr: Weighing the client every 48 hours may not provide sufficient monitoring during the first week, as weight changes can occur rapidly in clients with anorexia nervosa. Daily weights are typically recommended during the initial phase of treatment.
D. Allow the client to eat meals in their room: Allowing the client to eat meals in their room may contribute to further isolation and avoidance of social interaction, which can exacerbate symptoms of anorexia nervosa. It's important to encourage meal consumption in a supportive environment, such as a dining area, where the client can receive encouragement and monitoring from staff and peers.

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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

A nurse is teaching the parents of a school-age child who has sickle cell anemia about managing the disease at home. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Correct Answer is A

Explanation

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