A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?
Encourage the toddler to flush the toilet while still seated.
Have the toddler remain on the toilet for a minimum of 20 min.
Wake the toddler every 2 hr. in the night to prevent bed-wetting.
Give the toddler a sticker after each successful toileting attempt.
The Correct Answer is D
A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.
B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.
C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.
D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. BUN 20 mg/dL: This is not specific to HELLP syndrome. A BUN level of 20 mg/dL is within the normal range and does not indicate the presence of HELLP syndrome, which is associated with liver dysfunction and low platelet count.
B. Platelet count 77,000/mm3: This is correct. HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelets) is characterized by a low platelet count, often less than 100,000/mm3, which is a critical indicator of this condition.
C. Hemoglobin 12 g/dL: This is a normal hemoglobin level and is not typically associated with HELLP syndrome, where hemolysis (destruction of red blood cells) can cause anemia, which would lower hemoglobin levels.
D. WBC count 18,000/mm3: While an elevated WBC count can indicate infection or inflammation, it is not specifically associated with HELLP syndrome. The hallmark features of HELLP syndrome are low platelets and liver enzyme elevation, not elevated WBC.
Correct Answer is A
Explanation
A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.
B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.
C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.
D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.
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