A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
Allow the toddler to handle the equipment.
Thoroughly explain each procedure to the toddler.
Start the examination with routine immunizations.
Completely undress the toddler.
The Correct Answer is A
Allowing the toddler to explore and handle the equipment, such as a stethoscope or blood pressure cuff, can help familiarize them with the objects and reduce anxiety. It can be done under the supervision of the nurse to ensure safety.
Starting the examination with routine immunizations can be helpful because it allows the child to get through potentially uncomfortable or distressing procedures early on. It can also create a positive association between the examination and a sense of relief after receiving vaccinations. While it is important to provide age-appropriate explanations to the toddler, it's essential to keep the explanations simple and concise. Using child-friendly language and demonstrating the procedure using dolls or toys can help the toddler understand what will happen during the examination.
Instead of completely undressing the toddler, it is generally more comfortable and less distressing to only partially undress them. For example, the nurse can ask the caregiver to remove the toddler's shirt while leaving the pants on. This approach helps maintain the child's sense of security and provides a level of modesty.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
Correct Answer is D
Explanation
The priority is to address any significant changes in the child's behavior, such as withdrawal, as it may indicate emotional or psychological distress. Switching daycare providers can be a significant event for a young child, and it is essential to explore the reasons behind the child's withdrawal and address any potential underlying issues. The nurse should gather more information, assess the child's emotional well-being, and discuss any concerns or observations with the guardian. This will help identify appropriate interventions or support for the child's emotional adjustment.
While the other statements may also warrant attention, the potential emotional impact of the daycare provider change on the child's behavior and well-being takes priority in this case. The nurse should address the other concerns raised by the guardian during the assessment process, but the immediate focus should be on addressing the child's withdrawal and ensuring their emotional well-being.
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