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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Respiratory: While respiratory symptoms can occur in Kawasaki disease, they are not the primary concern.
B. Gastrointestinal: Gastrointestinal symptoms can occur in Kawasaki disease, but they are not the primary concern.
C. Integumentary: Although Kawasaki disease can cause symptoms such as a rash and peeling skin, these are not the primary concerns.
D. Cardiovascular: This is the correct answer. Kawasaki disease can lead to serious complications involving the heart, such as coronary artery aneurysms. Therefore, monitoring the cardiovascular system is crucial in managing this condition.
Correct Answer is D
Explanation
A. Cranberry juice: This is generally safe to consume after a tonsillectomy. It is not acidic and will not irritate the throat.
B. Crushed ice: This can be soothing for the throat after a tonsillectomy and can help reduce swelling.
C. Vanilla milkshake: While dairy products can sometimes cause phlegm to thicken, making it harder to swallow, they are generally considered safe after a tonsillectomy unless the child has a known dairy allergy or intolerance.
D. Orange juice: This is the correct answer. Orange juice is acidic and can irritate the throat after a tonsillectomy, so it should be avoided.
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