A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

Encourage the family to be with the child during mealtimes.

Instruct the family to praise the child when they eat.

Obtain the child's dietary history.

Offer the child nutritious snacks between meals.

Answer and Explanation

The Correct Answer is C

A. Encourage the family to be with the child during mealtimes. While having family present can provide support and create a positive mealtime atmosphere, it is not the first step in addressing poor dietary intake. Understanding the underlying reasons for the child's poor intake is more critical initially.
B. Instruct the family to praise the child when they eat. Encouraging praise can help create a positive association with eating, but this action is more effective after understanding the child's dietary habits and preferences.
C. Obtain the child's dietary history. Obtaining the child's dietary history is the most important first step. This allows the nurse to identify specific concerns, such as food preferences, patterns of intake, and any potential food allergies or intolerances. Understanding the child's current dietary habits is essential for developing an effective plan to improve nutritional intake.
D. Offer the child nutritious snacks between meals. Offering nutritious snacks can help increase caloric intake, but this should be done after assessing the child's dietary history to ensure that the snacks are appropriate and tailored to the child's needs and preferences.

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Correct Answer is B

Explanation

A. Tongue blade. Placing a tongue blade in a client’s mouth during a seizure is contraindicated as it can cause injury, break teeth, or obstruct the airway. Nothing should be inserted into the client’s mouth during a seizure.
B. Suction machine. This is essential for clearing the airway of excessive secretions or vomit following a seizure, reducing the risk of aspiration. Maintaining airway patency is a priority in seizure management.
C. NG tube. This is not necessary for immediate seizure management. Nasogastric tubes are used for gastric decompression, feeding, or medication administration but do not play a direct role in seizure care.
D. Syringe containing lorazepam. While lorazepam is used to stop prolonged seizures, it is typically stored in a secured medication area rather than kept at the bedside. Emergency medications should be readily available but not pre-drawn or left unsecured.

A. A client who is postoperative and has a Jackson-Pratt drain B. A client who is scheduled for surgery in 2 hr C. A client whose blood pressure is 160/90 mm Hg and reports a headache D. A client who is postoperative and reports intermittent nausea

Correct Answer is C

Explanation

A. A client who is postoperative and has a Jackson-Pratt drain. A Jackson-Pratt drain is a routine postoperative device used to prevent fluid accumulation. Unless there are signs of excessive drainage, infection, or blockage, this client does not require immediate attention.
B. A client who is scheduled for surgery in 2 hr. While preoperative preparation is important, it is not the most urgent concern. This client can be attended to after addressing more pressing clinical issues, such as potential hypertensive complications.
C. A client whose blood pressure is 160/90 mm Hg and reports a headache. A significantly elevated blood pressure with a headache may indicate a hypertensive crisis, which increases the risk of stroke or other complications. This client should be assessed immediately to determine the severity and need for intervention.
D. A client who is postoperative and reports intermittent nausea. Nausea is a common postoperative symptom and can often be managed with antiemetics and dietary modifications. It does not pose an immediate life-threatening risk compared to possible hypertensive emergencies.

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A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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