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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. Perform chest physiotherapy: This is typically used for clients with respiratory conditions that cause mucus to build up in the lungs, not for preventing aspiration in a post-tonsillectomy client.
B. Withhold fluids until the client demonstrates a gag reflex: This is the correct answer. After a tonsillectomy, the client’s throat may be numb from local anesthetics, and they may not have a fully functioning gag reflex. Giving fluids before the gag reflex returns could lead to aspiration.
C. Suction the nasopharynx as needed: While suctioning can help clear the airway, it’s not typically done routinely after a tonsillectomy unless the client is having difficulty clearing secretions on their own.
D. Place a bedside humidifier at the head of the client’s bed: While this can help soothe a sore throat after a tonsillectomy, it won’t necessarily prevent aspiration. It’s more important to ensure the client’s gag reflex has returned before giving fluids.

Correct Answer is A

Explanation

A. Influenza, live attenuated (LAIV): This is the correct answer. The production of this vaccine involves the use of chicken eggs, and it may contain traces of egg protein. Therefore, it should be avoided in individuals with a severe egg allergy.
B. Haemophilus influenza type b (Hib): This vaccine is not contraindicated for individuals with an egg allergy as it does not contain egg protein.
C. Hepatitis B (HepB): This vaccine is safe for individuals with an egg allergy as it does not contain egg protein.
D. Inactivated poliovirus (IPV): This vaccine is not contraindicated for individuals with an egg allergy as it does not contain egg protein.

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