An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to.
Ask her why she wants to know.
Determine why she is so anxious.
Explain in simple terms how it works.
Tell her she will see how it works as it is used.
The Correct Answer is C
The correct answer is choice C. Explain in simple terms how it works.
Choice A rationale:
Asking the girl why she wants to know might be appropriate in some contexts, but children are naturally curious and seeking information is a common behavior. Explaining how the blood pressure apparatus works would likely be more beneficial than questioning her motivation.
Choice B rationale:
Determining why she is anxious assumes that the girl is anxious, which might not be the case. Additionally, the question she asked does not necessarily indicate anxiety, but rather a curiosity about the medical equipment.
Choice C rationale:
Explaining in simple terms how the blood pressure apparatus works is the most appropriate nursing action. This approach respects the child's curiosity and provides her with age-appropriate information, fostering a positive and educational interaction.
Choice D rationale:
Telling her that she will see how it works as it is used might not fully satisfy her curiosity or address her immediate question. Children often benefit from clear and concise explanations, especially when it comes to medical equipment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Decreased urinary output can be a sign of heart failure, especially in infants. In heart failure, the heart's ability to pump effectively can lead to decreased blood flow to the kidneys, resulting in decreased urine production.
Choice B rationale:
Sweating (inappropriate) is a symptom of heart failure in infants. Infants with heart failure might sweat excessively, especially while feeding or crying, due to the effort required by the heart to pump blood effectively.
Choice C rationale:
Warm flushed extremities are not typically associated with heart failure in infants. In heart failure, extremities might actually become cool and pale due to poor circulation.
Choice D rationale:
Anorexia, or a lack of appetite, is a common sign in infants with heart failure. The increased effort required for feeding due to compromised cardiac function can lead to poor feeding and decreased appetite.
Choice E rationale:
Weight loss can occur in infants with heart failure due to inadequate caloric intake, difficulty with feeding, and increased metabolic demands associated with heart failure. However, it's not as specific a sign as decreased urinary output, sweating, and anorexia.
Correct Answer is ["A","C","D"]
Explanation
The correct answers are choices A, C, and D: Tachycardia, Hyperthermia, and Vomiting.
Choice A rationale:
Tachycardia. Tachycardia, an abnormally fast heart rate, is a classic manifestation of thyroid storm. In this life-threatening condition, there is an excessive release of thyroid hormones, leading to increased metabolic rate and subsequent cardiovascular effects such as tachycardia.
Choice B rationale:
Constipation. This choice is incorrect for thyroid storm. Hyperthyroidism typically leads to increased bowel motility and can cause diarrhea rather than constipation.
Choice C rationale:
Hyperthermia. This is a correct choice. Thyroid storm is associated with severe hyperthermia due to the increased metabolic rate caused by excessive thyroid hormones. The body's temperature regulation is disrupted, leading to dangerously high body temperatures.
Choice D rationale:
Vomiting. This is a correct choice. Gastrointestinal symptoms, including vomiting and nausea, can occur in thyroid storm due to the heightened metabolic state. Thyroid storm affects various systems, including the gastrointestinal system, leading to symptoms like vomiting.
Choice E rationale:
Hypotension. This choice is incorrect for thyroid storm. Thyroid storm is more likely to cause hypertension rather than hypotension due to the increased cardiac output and sympathetic stimulation.
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