The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?
Obtaining an order to have an indwelling urinary catheter inserted.
Weighing the patient's wet diapers prior to discarding them.
Sitting the patient on the bedpan at least every two hours.
Applying a pediatric urine collection device over the patient's urinary meatus.
The Correct Answer is B
Weighing the patient's wet diapers prior to discarding them.
Choice A rationale:
Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.
Choice B rationale:
Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.
Choice C rationale:
Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.
Choice D rationale:
Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.
Choice B rationale:
Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.
Choice C rationale:
Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.
Choice D rationale:
Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.
Correct Answer is B
Explanation
Choice A rationale:
Inquiring about pain after surgery is a normal concern for a mother, but it doesn't necessarily indicate successful progress in attachment. It shows concern for the baby's well-being, but attachment involves more emotional and bonding aspects.
Choice B rationale:
Expressing joy in seeing the baby empty her formula bottle during feeding demonstrates an emotional connection and maternal satisfaction with providing for the infant's needs. This suggests successful attachment and bonding between the mother and baby.
Choice C rationale:
Concerns about the scar from surgery indicate the mother's focus on the physical appearance of the baby, which is not the primary marker of successful attachment. It reflects a different aspect of the mother's thoughts and emotions.
Choice D rationale:
Noting similarities in physical features doesn't necessarily indicate a deeper attachment. While it's a natural observation, attachment involves more emotional bonding than just physical resemblances.
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