A nurse is preparing to collect data from a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply.)
Answers questions asked by the nurse
Plays with toys in the examining room
Makes eye contact with the nurse
Allows the nurse to touch him on the arm
Sits on his parent's lap when the nurse enters the room
Correct Answer : A,C,D
A. Answers questions asked by the nurse: Responding verbally shows the child is engaged and able to understand and participate in the interaction, indicating readiness to cooperate during the assessment.
B. Plays with toys in the examining room: While playing indicates comfort in the environment, it may also reflect distraction or avoidance rather than readiness to cooperate with the nurse’s instructions. Play alone is not a reliable indicator of cooperation.
C. Makes eye contact with the nurse: Eye contact demonstrates attention and willingness to engage with the nurse, which is a positive sign that the child is prepared to follow directions during data collection.
D. Allows the nurse to touch him on the arm: Tolerating touch shows trust and comfort with the nurse’s presence and interventions, signaling the child is ready to participate in the assessment.
E. Sits on his parent's lap when the nurse enters the room: Sitting on a parent’s lap may indicate the child is seeking comfort and security rather than being ready to cooperate independently. This behavior alone does not confirm readiness for assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "I will notify my doctor if the stoma starts to look purple.": A stoma that appears purple can indicate compromised blood flow or ischemia, which is a medical emergency. Recognizing this sign and notifying the healthcare provider demonstrates understanding of proper stoma care and potential complications.
B. "I will irrigate the colostomy every day.": Ascending colostomies typically produce liquid to semi-liquid stool and are not routinely irrigated. Daily irrigation is usually reserved for descending or sigmoid colostomies to regulate bowel movements.
C. "I should expect my stool to be formed.": Stool from an ascending colostomy is usually liquid or semi-liquid because the stool has not yet passed through the majority of the colon where water absorption occurs. Expecting formed stool indicates a misunderstanding of colostomy output.
D. "I will empty the pouch every 2 to 3 hours.": Ascending colostomy output is frequent and liquid, but pouches are generally emptied when they are one-third to one-half full, not on a strict schedule. Overly frequent emptying is unnecessary and may increase the risk of skin irritation.
Correct Answer is D
Explanation
A. Reviewing the results of the client's urinalysis with their parents, without the client's consent: Routine urinalysis results are generally considered part of standard adolescent care and may be shared with parents depending on the clinic policy and state laws, so this may not necessarily breach confidentiality.
B. Reviewing the results of the client's celiac screening with their parents, without the client's consent: Celiac screening is part of general health testing and usually does not fall under sensitive health information; sharing these results with parents is typically permissible in pediatric care.
C. Reviewing the results of the client's complete blood count (CBC) with their parents, without the client's consent: A CBC is standard lab work and does not usually involve sensitive information, so sharing results with parents is generally acceptable and not considered a breach of confidentiality.
D. Reviewing the results of the client's chlamydia screening with their parents, without the client's consent: STI testing is considered confidential for adolescents, and sharing these results without consent violates privacy laws and ethical guidelines. Protecting confidentiality encourages adolescents to seek care and be honest about sexual health.
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