Which is the priority nursing action when performing a physical assessment on a toddler?
1. Leaving intrusive procedures such as eye and ear examinations until the end
2. Explaining each part of the examination to the child before performing it
3. Performing the assessment from head to toe
4. Asking the mother to tell the child not to be afraid
1
Explanation:
1. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs.
2. A toddler is too young to understand the medical terminology.
3. Intrusive procedures such as examinations of the eyes, ears, throat, and genitals should be done last to decrease the anxiety of the child during the initial phases of the examination, which include heart and lungs.
4. Asking the mother to tell the child not to be afraid is an inappropriate response.
You might also like to view...
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
a. Valvular disorder. b. Blood flow turbulence. c. Fluid volume overload. d. Ventricular hypertrophy.
The intervention appropriate for an antisocial client with a nursing diagnosis of ineffective coping
related to manipulation of others is to a. refer requests and questions related to care to the primary nurse. b. provide negative reinforcement for acting-out behavior. c. ignore, rather than confront, inappropriate behavior. d. encourage the client to discuss feelings of fear and inferiority.
Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications?
A) The fire was caused by burning weeds. B) The child's clothing was burned. C) The child was trapped in a closed burning bedroom. D) Firemen found the child sobbing silently.
The nurse identifies the specific indicators and focal areas needed to establish immunization and well-child clinics in a low-income neighborhood. What actions are needed to meet the health outcomes of the project?
A) Identify the need in the community for the clinic on the basis of subjective data. B) Develop a plan to meet the costs and promote the benefits of the project. C) Consider the identified neighborhood's need for healthcare compared with that of other low-income neighborhoods by interviewing the members of the neighborhood. D) Assume that the neighborhood will welcome the institution of a well-child and immunization clinic.