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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?

A.

"I am going to listen to your heart."

B.

"Can I listen to your lungs?"

C.

"I am going to take your blood pressure now."

D.

"Can you stand very still while I feel how warm you are?"

Answer and Explanation

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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Related Questions

Correct Answer is B

Explanation

A. Heart rate 72/min: This is within the normal range for an adolescent.

B. Blood pressure 92/50 mm Hg: This is concerning because it’s lower than the normal range for an adolescent, which could indicate shock, a serious condition that requires immediate medical attention.

C. Respiratory rate 20/min: This is within the normal range for an adolescent.

D. Abdominal pain rated 4 on a scale of 0 to 10: While any pain is concerning, a pain level of 4 is less immediately concerning than the low blood pressure. Therefore, option B is the most concerning finding.

Correct Answer is B

Explanation

Insert an IV catheter: While this might be necessary later, it’s not the immediate priority. The child’s breathing difficulty is the most urgent concern.
B. Prepare for nasotracheal intubation: This is the correct answer. The child’s severe dyspnea indicates a serious breathing problem. Nasotracheal intubation can help ensure the child’s airway remains open.
C. Administer an antipyretic: While this might help reduce the child’s fever, it won’t address the immediate life-threatening issue, which is the child’s difficulty breathing.
D. Obtain blood culture specimens: This could be helpful in diagnosing the cause of the child’s symptoms, but it’s not the immediate priority. The first concern should be stabilizing the child’s condition.

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