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 B
Explanation
The correct answer is choice B. First stage.
Choice A rationale:
There is no fourth stage of Lyme disease. Lyme disease typically progresses through three stages: early localized, early disseminated, and late disseminated. The symptoms mentioned in the question are more indicative of earlier stages of the disease.
Choice B rationale:
The child is likely exhibiting symptoms of the first stage of Lyme disease, known as early localized Lyme disease. This stage is characterized by the appearance of small annular (circular) lesions known as erythema migrans. These lesions are often red and have a clear center, resembling a "bull's-eye" pattern. This stage occurs within days to weeks after a tick bite and is usually accompanied by flu-like symptoms.
Choice C rationale:
There is no third stage of Lyme disease. The third stage is considered the late disseminated stage, which occurs months to years after the initial infection. It typically involves more severe symptoms, such as arthritis, neurological issues, and cardiac abnormalities.
Choice D rationale:
There is no second stage of Lyme disease. The second stage is the early disseminated stage, which occurs weeks to a few months after the tick bite. It involves the spread of the bacteria to other parts of the body, leading to symptoms such as multiple erythema migrans lesions, flu-like symptoms, fatigue, and muscle and joint pain.
Correct Answer is A
Explanation
The correct answer is choice A. Potassium.
Choice A rationale:
Diuretics like furosemide are commonly used to treat congestive heart failure. They work by increasing the excretion of water and electrolytes, including potassium, from the body. Low levels of potassium (hypokalemia) can lead to various complications, including cardiac arrhythmias and muscle weakness. Since furosemide can cause potassium loss, it's important to ensure an adequate intake of potassium-rich foods. Bananas, oranges, and leafy vegetables are excellent sources of potassium. Therefore, the nurse encourages the family to include these foods in the child's diet to help maintain a healthy potassium balance.
Choice B rationale:
Sodium is an important electrolyte, but in the context of congestive heart failure and diuretic use, the focus is more on avoiding excessive sodium intake. Diuretics like furosemide aim to reduce fluid retention by increasing sodium excretion, so it's not necessary to recommend high-sodium foods. Moreover, excessive sodium intake could exacerbate fluid retention and worsen the heart failure.
Choice C rationale:
Chlorides are often found in table salt (sodium chloride) and are not typically emphasized in the context of heart failure treatment or diuretic use. While they play a role in maintaining electrolyte balance, they are not the primary focus in this scenario.
Choice D rationale:
Zinc is a mineral that is not directly related to the treatment of congestive heart failure or the use of diuretics. It is important for various cellular functions and immune system support, but it's not the electrolyte of concern in this situation.
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