A nurse is preparing a school-age child for an invasive procedure.
Which of the following actions should the nurse plan to take?
Use vague language to describe the procedure.
Plan for a 30 min teaching session about the procedure.
Explain the procedure to the child when they are in the playroom.
Demonstrate deep-breathing and counting exercises.
The Correct Answer is D
The correct answer is choice d. Demonstrate deep-breathing and counting exercises.
Choice A rationale:
Using vague language to describe the procedure can increase anxiety and fear in the child. Clear and age-appropriate explanations help the child understand what to expect.
Choice B rationale:
A 30-minute teaching session may be too long for a school-age child, leading to loss of attention and increased anxiety. Short, focused sessions are more effective.
Choice C rationale:
Explaining the procedure in the playroom can associate a place of comfort with stress and anxiety. It’s better to explain the procedure in a neutral or medical setting.
Choice D rationale:
Demonstrating deep-breathing and counting exercises helps the child manage anxiety and pain during the procedure. These techniques are effective coping strategies for children undergoing medical procedures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Unable to hold a bottle is a developmental milestone expected at around 6 months of age. This is not a concerning finding for a 5-month-old infant.
Choice B rationale:
The grasp reflex is present in infants until about 6 months of age. Its absence is expected at 5 months and is not a cause for concern.
Choice C rationale:
Rolling from back to abdomen is typically achieved by 5 months of age. However, the inability to do so is not necessarily a red flag at this age, as each infant develops at their own pace.
Choice D rationale:
Head lag refers to the infant's head falling backward when pulled to a sitting position, indicating poor head control. This is a significant developmental red flag at 5 months of age and should be reported to the provider. It might indicate possible neuromuscular issues or developmental delays, requiring further evaluation and intervention.
Correct Answer is C
Explanation
When caring for a school-age child immediately following a tonsillectomy in the Post-Anesthesia Care Unit (PACU), the nurse should prioritize actions that promote the child's comfort and recovery while minimizing the risk of complications. The most appropriate action is:
c) Offer the child ice cream when alert.
After a tonsillectomy, cold and soothing foods like ice cream can help alleviate throat pain and reduce swelling. However, it's crucial to wait until the child is fully alert and able to swallow safely. Ice cream provides a cool and gentle way to soothe the surgical site.
The other options may not be suitable immediately following a tonsillectomy:
a) Placing the child in a side-lying position: While positioning can be essential for airway management, it's not a specific intervention related to a tonsillectomy in the immediate postoperative period.
b) Instructing the child to drink fluids through a straw: Drinking through a straw may increase the risk of bleeding, which is a concern after a tonsillectomy. It's often recommended to avoid straws initially.
d) Encouraging the child to deep breathe and cough: While respiratory care is generally important, the immediate focus after a tonsillectomy is on maintaining a clear airway and managing pain. Deep breathing and coughing exercises may be introduced later in the recovery process.
It's important for the nurse to follow the specific postoperative guidelines provided by the surgical team and be attentive to the child's individual needs and responses.
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