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?

Obtain the child's dietary history.

Offer the child nutritious snacks between meals.

Encourage the family to be with the child during mealtimes.

Instruct the family to praise the child when they eat.

Answer and Explanation

The Correct Answer is A

A.   Correct. Gathering information about the child's dietary history is the first step to understanding the potential underlying causes of poor intake.
B.   Incorrect. Offering nutritious snacks is important, but understanding the child's history is a higher priority.
C.   Incorrect. While family presence during mealtimes is important, addressing the child's dietary intake takes precedence.
D.   Incorrect. Praise is important but doesn't address the underlying issue of poor dietary intake.

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Correct Answer is B

Explanation

A.Restraints should be released more frequently, typically every 2 hours, to assess circulation, skin integrity, and range of motion, and to provide an opportunity for toileting and other needs.

B.It is essential to document the specific behaviors that led to the use of restraints, as this provides a clear rationale for why the restraints were necessary. This documentation is important for legal and clinical reasons and helps ensure that restraints are used appropriately and only when absolutely necessary.

C.Clients are not required to provide written consent for the use of restraints, especially in situations where restraints are necessary to protect the client or others from immediate harm. However, the nurse must follow the facility's protocol, which usually involves obtaining a physician's order and documenting the justification for the restraint use.

D.The nurse should check the client's status more frequently, typically every 15 minutes, to ensure the client's safety and well-being while in restraints.

A. Recurring urinary tract infections B. A recent move to a new city C. Lack of nutritional knowledge D. Report of feeling depressed

Correct Answer is B

Explanation

A. Incorrect. Recurring urinary tract infections are related to health and hygiene and are not typically considered external stressors.
B. Correct. A recent move to a new city is an external stressor because it is an environmental change that can lead to feelings of stress and adjustment.
C. Incorrect. Lack of nutritional knowledge is an internal stressor related to the client's knowledge and awareness, not an external factor.
D. Incorrect. Feeling depressed is an internal emotional state and is not an external stressor.

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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?

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