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 B,A,D,C
Explanation
A. Examine personal thoughts and feelings about meeting the client: The nurse should first engage in self-reflection to identify any biases, anxieties, or expectations. This helps ensure that personal feelings do not interfere with establishing a therapeutic and professional relationship with the client.
B. Introduce self and set goals for the relationship: After self-reflection, the nurse introduces themselves to the client and collaboratively establishes the goals and boundaries of the therapeutic relationship. This step builds trust and sets clear expectations for interactions.
C. Assist the client with identifying problem-solving techniques: Once the relationship is established, the nurse helps the client develop coping and problem-solving strategies. This step supports the client’s growth, autonomy, and ability to manage challenges effectively.
D. Summarize the achievement of goals that have been met: At the conclusion of the therapeutic relationship, the nurse reviews progress with the client and summarizes goals that were achieved. This reinforces accomplishments, encourages continued growth, and provides closure to the relationship.
Correct Answer is ["B","D","F","G"]
Explanation
Rationale for correct choices:
• Deep tendon reflexes 2+ bilaterally: DTRs decreased from 3+ to 2+, indicating reduced hyperreflexia. Hyperreflexia is a hallmark of preeclampsia and HELLP syndrome; improvement suggests that neuromuscular excitability and central nervous system irritability are stabilizing. Monitoring DTRs helps evaluate treatment effectiveness and risk reduction for complications.
• Oxygen saturation (SaO₂) 95% on 2 L nasal cannula: Oxygenation is within acceptable limits for a patient on supplemental oxygen. Maintaining adequate maternal oxygenation supports fetal perfusion and reduces hypoxic stress. Improved oxygen saturation reflects better respiratory status and cardiovascular stability compared with prior readings (SaO₂ 92–94%).
• Respiratory rate 18/min: The client’s respiratory rate is within normal limits, improving from earlier tachypnea (24/min). Stabilization of respiratory rate indicates reduced distress, better oxygenation, and improved overall maternal status, which contributes to safer outcomes for both mother and fetus.
• Blood pressure 146/96 mm Hg: At 1400, the client’s blood pressure had spiked to a very dangerous 170/112 mm Hg (severe hypertension). The decrease to 146/96 mm Hg by 1800 indicates that medical interventions are successfully lowering the pressure toward a safer range.
Rationale for incorrect choices:
• Temperature 38.3° C (101° F): The client’s temperature is elevated, indicating fever. Fever does not reflect improvement and may signal infection, inflammation, or other complications. Ongoing assessment and intervention are required to address the cause of hyperthermia.
• Urine output 40 mL: A single low urine output reading suggests oliguria, which is concerning in preeclampsia or HELLP syndrome. Adequate renal perfusion is essential; this value does not indicate improvement and requires ongoing monitoring.
• Heart rate 58/min: Bradycardia may be related to medications, vagal stimulation, or underlying cardiovascular changes. While it is a change from prior tachycardia, bradycardia itself is not an indicator of improvement and may require further evaluation.
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