A nurse is preparing to perform a physical assessment on a toddler. Which of these actions should the nurse take?
1. Explain each part of the examination to the child before performing it.
2. Ask the mother to tell the child not to be afraid.
3. Perform the assessment from head to toe.
4. Leave intrusive procedures, such as ear and eye examinations, until the end.
4
Rationale 1: Explaining each part before performing it will only make the child more fearful, as it will make the entire procedure last longer.
Rationale 2: This will do little to alleviate the child's fears.
Rationale 3: The nurse should complete the assessment in whichever order does not upset the child, leaving the head and genital areas for last.
Rationale 4: Intrusive procedures, such as examination of the ears, throat, eye, and genital areas, should be done last to decrease the anxiety of the child during the initial phases of the examination, which include the heart and lungs.
Global Rationale:
You might also like to view...
A 21-year-old woman presents with cytomegalovirus (CMV). The LPN says, "I've never heard of CMV before." The nurse explains to the LPN that this infection is most often seen with patients diagnosed with what?
A) HIV B) Influenza C) Autoimmune disorder D) Hepatitis B
Which intervention may be used to decrease the intracranial pressure (ICP) of a client who has sustained a head injury?
a. administration of antibiotics b. administration of corticosteroids and osmotic diuretics c. passive range of motion every 3 to 4 hours d. antacids and histamine receptor antagonists
A 17-year-old female patient complains of amenorrhea for the last 8 months, weight gain, excessive hair growth on the arms and chest, and development of acne. Pelvic examination is normal. The clinician should recognize these are signs of:
A. Ovarian cancer B. Endometriosis C. Hormonal imbalance D. Stress-induced anovulation
A patient tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on which of the following?
A) Habitual laxative use is the most common cause of chronic constipation. B) If laxatives are not effective, the patient should begin to use enemas. C) A laxative that works by a different method should be used. D) Chronic constipation is nothing to be concerned about.