A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?
"I am going to listen to your heart."
"Can I listen to your lungs?"
"I am going to take your blood pressure now."
"Can you stand very still while I feel how warm you are?"
The Correct Answer is A
A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Feelings of isolation: This is the correct answer. Isotretinoin has been linked to depression and suicidal ideation in some cases. Therefore, any changes in mood, including feelings of isolation, should be reported to the healthcare provider immediately.
B. Itching of skin: While this can be a side effect of isotretinoin, it is not as critical as changes in mood. However, any discomfort should still be reported to the healthcare provider.
C. Back pain: This can be a side effect of isotretinoin, but it is not as critical as changes in mood. However, any discomfort should still be reported to the healthcare provider.
D. Frequent nosebleeds: This can be a side effect of isotretinoin due to dryness of the nasal passages, but it is not as critical as changes in mood. However, any discomfort should still be reported to the healthcare provider.
Correct Answer is B
Explanation
A. Percuss each lung segment for 15 min: While percussion is a part of chest physiotherapy, it doesn’t typically need to be performed for 15 minutes per lung segment. The duration can vary based on the child’s needs and tolerance.
B. Administer albuterol prior to CPT: This is the correct answer. Albuterol is a bronchodilator that can help open the airways and make the chest physiotherapy more effective.
C. Perform CPT immediately after the child eats: This is not recommended because it can increase the risk of vomiting. It’s usually better to perform CPT before meals or at least 1 hour after meals.
D. Perform vibration during the client’s inspirations: Vibration is typically performed during exhalation, not inspiration, to help loosen and mobilize secretions in the lungs.
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