A nurse is collecting a health history from the guardian of a 4year old child. Which of the following statements by the guardian is the priority for the nurse to address?
I have a difficult time getting my child to eat green vegetables
My child continually asks me the same questions
My child still wets the bed at least two times per week
I have noticed that my child is withdrawn since we switched day care providers
The Correct Answer is D
A) I have a difficult time getting my child to eat green vegetables: While it’s common for preschoolers to be selective about food, especially vegetables, this issue does not represent an immediate concern for the child’s health or development. This issue can often be addressed with strategies to encourage healthy eating, but it is not as urgent as other concerns.
B) My child continually asks me the same questions: Repetitive questioning is a normal part of preschool development, as children at this age are curious and often seek reassurance. It reflects their cognitive development as they try to understand the world around them. While it may be tiring for the guardian, it is not an immediate concern.
C) My child still wets the bed at least two times per week: Bedwetting (enuresis) is common among preschool-aged children, and many children do not gain full bladder control until after age 5. This issue is typically addressed if it continues past the age of 5, but it is not a priority at this time.
D) I have noticed that my child is withdrawn since we switched day care providers: This statement indicates a potential emotional or behavioral issue that requires immediate attention. Changes in behavior, such as withdrawal, can be a sign of stress, anxiety, or difficulty adjusting to a new environment. The nurse should prioritize this concern, as it may indicate that the child is having difficulty coping with the transition and may need additional support or evaluation. Addressing emotional well-being is a priority for the nurse.
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Related Questions
Correct Answer is C
Explanation
A) NG tube: A nasogastric (NG) tube is not typically required for a client with a seizure disorder unless they have specific feeding or aspiration concerns that require tube feeding. During a seizure, the priority is to ensure airway clearance and prevent injury, not necessarily to provide nutrition through an NG tube.
B) Tongue blade: It is a common myth that tongue blades should be used to prevent a client from biting their tongue during a seizure. However, using a tongue blade can be dangerous as it can cause injury to the mouth or teeth, or even cause choking. The nurse should never attempt to place anything in the client's mouth during a seizure.
C) Suction machine: A suction machine is essential for maintaining airway patency during or after a seizure. Clients with seizure disorders may be at risk for aspiration, and the suction machine can be used to clear secretions from the mouth to prevent choking or aspiration pneumonia. This is the most appropriate supply to place at the bedside.
D) Syringe containing lorazepam: While lorazepam (a benzodiazepine) is sometimes used for acute seizure management, it is not a routine item to have immediately at the bedside unless specifically ordered for emergency seizure intervention. The nurse should follow protocol and administer medications as prescribed, but a syringe of lorazepam is not typically pre-placed at the bedside.
Correct Answer is B
Explanation
A) Medical health insurance claims:
Medical health insurance claims are not relevant to the referral for physical therapy. This information is typically handled by billing departments and insurance providers. The focus of a physical therapy referral is on the patient's clinical condition and needs, not their insurance coverage.
B) Physical assessment findings:
This is the most relevant information to include in a referral for physical therapy. The physical assessment findings provide the physical therapist with important details about the client's mobility, strength, range of motion, and other factors that can guide the creation of an individualized therapy plan. These findings help the therapist understand the client's current physical capabilities and limitations.
C) Medications taken prior to admission:
While it is important for the healthcare team to be aware of the medications a client is taking, this information is not as crucial for the physical therapy referral itself. The physical therapist may need to know about medications if they have a direct impact on the client's physical functioning (e.g., sedatives or pain medications), but the primary focus for the referral would be on the physical assessment findings.
D) Family medical history:
Family medical history is typically relevant to a broader health assessment but is not generally included in a referral for physical therapy. The therapist will be more concerned with the client's current physical condition and functional abilities rather than the medical history of the client's family.
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