A nurse is assisting with the care of a client.

The nurse is collecting data from the client.

Select words from the choices to fill in each blank in the following sentence

The nurse should identify that

____

and

____

Indicate manifestations of borderline personality disorder

A) Completely undress the toddler:
Completely undressing a toddler can cause unnecessary distress and anxiety, especially if they are not prepared for the examination. It’s more appropriate to undress the toddler only as needed for the physical exam and allow them to remain clothed or partially clothed whenever possible to help them feel secure.

B) Allow the toddler to handle the equipment:
Allowing a toddler to handle the medical equipment is an excellent way to reduce fear and anxiety. This familiarizes the child with the instruments and allows them to feel more in control of the situation. It also helps in building trust with the nurse, making the examination less intimidating for the toddler.

C) Start the examination with routine immunizations:
Immunizations can be particularly stressful for toddlers, so starting the examination with vaccines is not the best approach. It’s better to begin with non-invasive procedures, such as listening to the heart or measuring the toddler’s height and weight, to build rapport before proceeding to any painful procedures.

D) Thoroughly explain each procedure to the toddler:
While it’s important to explain the examination to the toddler in simple, age-appropriate language, toddlers typically have a limited understanding of detailed explanations. Over-explaining may increase anxiety. Instead, it's better to keep things brief and comforting, using simple phrases, and focus on creating a positive experience.

A) "I do not need to sign a consent form before this procedure": This statement is incorrect. Most procedures involving intravenous (IV) dye or contrast require the client to sign a consent form. This is because the procedure involves the use of a contrast agent that could have potential risks or side effects, and the client needs to be informed and give consent for its use.

B) "I will feel a warming sensation after the injection of the dye": This statement is correct. It is common for patients to experience a warming or flushing sensation after the injection of IV contrast dye. This feeling is typically temporary and a normal response to the dye being introduced into the bloodstream. The nurse should reassure the client about this sensation.

C) "I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. In most cases, clients are encouraged to increase their fluid intake after procedures involving IV contrast to help flush the dye from their system and prevent any potential kidney complications. Limiting fluid intake is generally not recommended unless otherwise instructed by the healthcare provider.

D) "I can have a meal up to 2 hours before the procedure": This statement is incorrect in many cases, especially if the procedure involves sedation or anesthesia. Typically, clients are instructed to fast for a period (usually 4–6 hours) before procedures involving contrast dye, particularly if anesthesia or sedation is used. Eating too soon before the procedure can increase the risk of aspiration or other complications. It’s important to follow specific instructions from the healthcare provider.