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
Deep-vein thrombosis (DVT) is a condition where a blood clot forms in a deep vein, usually in the legs. Bed rest is often recommended for clients with DVT to reduce the risk of the clot dislodging and causing a pulmonary embolism. By minimizing movement and keeping the leg elevated, the nurse can help prevent further complications.
The other options listed are incorrect:
- Massage the affected extremity every 4 hours: Massaging the affected extremity can dislodge the clot, increasing the risk of a pulmonary embolism. It is contraindicated and should not be performed in clients with DVT.
- Apply an ice pack to the affected extremity for 20 minutes every 2 hours: While applying cold compresses or ice packs may be useful in some situations to reduce swelling or pain, it is not recommended for clients with DVT. Heat application or cold application should be avoided because they can promote blood circulation and potentially dislodge the clot.
- Administer aspirin for pain: Aspirin is not typically used for pain management in DVT. Anticoagulant therapy is the primary treatment for DVT, and specific anticoagulant medications are prescribed to prevent further clot formation and reduce the risk of complications.
Correct Answer is ["C","D","F","G","H"]
Explanation
A.a. Heart rate (98/min): A heart rate of 98/min is within the normal range for adults (60-100 bpm). This does not indicate an immediate need for further evaluation based on the provided data.
B.Blood pressure (112/88 mmHg): The blood pressure reading is within normal limits. This does not suggest an immediate concern.
C. Temperature: The client reports a low-grade fever (38.1°C or 100.5°F), which suggests an ongoing infection or inflammatory process. Further evaluation is necessary.
D.Respiratory complaint: A productive cough with blood-tinged sputum, especially in combination with symptoms such as fatigue, night sweats, and weight loss, is concerning and warrants further evaluation for possible serious conditions such as tuberculosis (TB) or other respiratory infections.
e.Oxygen saturation (98% on room air):The oxygen saturation is normal. This finding does not indicate an immediate need for further evaluation.
F.Weight loss: The client reports a significant weight loss of 26 kg (5 lbs) over the past week. Unintentional weight loss can be a concerning symptom and may indicate an underlying medical condition that requires further investigation.
G.Sputum characteristics: Blood-tinged sputum, especially with other symptoms like cough, fever, and night sweats, can be indicative of serious conditions such as TB or other respiratory infections and needs further evaluation.
H.Travel history: Recent travel to a region where certain infectious diseases are prevalent (such as TB) is a critical factor that requires further evaluation in the context of the client's symptoms.
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