A nurse is planning to change the dressings on a school-age child who has sustained multiple burns. Which of the following actions should the nurse plan to take?
Explain long term consequences of the procedure to the child.
Remove the dressings while explaining the procedure to the child.
Keep equipment out of the child's sight.
Allow the child to help remove the dressings.
The Correct Answer is D
A. Explain long term consequences of the procedure to the child. This level of detail is not developmentally appropriate for a school-age child. It may increase anxiety without helping the child understand or cope with the immediate situation.
B. Remove the dressings while explaining the procedure to the child. While it is important to explain procedures, it should be done before starting to allow time for questions and emotional preparation. Explaining during may cause confusion or distraction.
C. Keep equipment out of the child's sight. Hiding equipment can actually increase fear and mistrust. School-age children benefit from open, age-appropriate communication and preparation about what to expect.
D. Allow the child to help remove the dressings. This is the most appropriate action. Allowing the child to participate in their care provides a sense of control, reduces anxiety, and helps build trust. It also aligns with the developmental need of school-age children to take on increasing responsibility and be involved in decision-making.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Place the client in a side-lying position for the procedure. Paracentesis is typically performed with the client in a high-Fowler’s or upright position, allowing fluid to collect in the lower abdomen for easier drainage.
B. Administer a low-volume hypertonic enema the night before the procedure. An enema is not required for a paracentesis, as the procedure involves the peritoneal cavity, not the bowel.
C. Weigh the client before and after the procedure. Weighing the client helps assess the amount of fluid removed and monitor for fluid shifts. It is a key part of pre- and post-procedural care to evaluate the effectiveness of the intervention.
D. Ensure the client has a full bladder just prior to the procedure. A full bladder increases the risk of injury during needle insertion. The bladder should be emptied before the procedure to prevent accidental puncture.
Correct Answer is A
Explanation
A. Wear loose-fitting clothing. After ICD implantation, the site may be sore or swollen, and tight clothing can cause irritation or pressure. Loose-fitting clothes help protect the incision and device, reducing discomfort and risk of complications.
B. Return in two weeks for a follow-up MRI. Most implantable cardioverter/defibrillators are not MRI-compatible unless specifically labeled as such. MRI exposure can interfere with device function and is generally avoided unless approved by a cardiologist.
C. Expect to have a rapid pulse rate for the first few weeks. The purpose of an ICD is to monitor and correct life-threatening arrhythmias, not to increase the heart rate. A rapid pulse is not expected and may indicate a complication requiring immediate evaluation.
D. Resume tub baths and swimming after 24 hr. Immersing the incision site in water within the first few weeks post-op increases the risk of infection. The client should avoid soaking the incision until it is fully healed, typically 1 to 2 weeks post-procedure.
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