The nurse is caring for a 4-year-old with a suspected urinary tract infection. Which approach would be best when attempting to obtain a urine specimen?
A) "I will need a urine sample from you."
B) "Let your mom help you tinkle in this cup."
C) "Would you please tinkle in this cup right now?"
D) "Please void in this cup instead of the toilet."
B
Response:
The nurse needs to use familiar terms to explain to the child what is needed and to gain cooperation. The most positive approach would be to let the child's mom help rather than demanding that the child tinkle right now. Using the terms "urine sample" or "void" is not appropriate for a 4-year-old.
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The Glasgow Coma Scale allows the nurse to objectively evaluate
A) eye-opening, motor, and pain response. B) eye-opening, motor, and verbal response. C) motor, verbal, and balance response. D) pain, verbal response, and balance.
The nurse is caring for a patient who will be undergoing bone marrow biopsy. Which statement by the patient indicates that additional teaching is needed?
a. "I will count the ceiling tiles when the doctor inserts the numbing medicine." b. "I will take acetaminophen (Tylenol) later today if the site becomes uncomfortable." c. "I will squeeze your hand to help calm my fears about the test." d. "I will keep the biopsy site clean and dry for the next 24 hours."
The nurse is caring for a patient who has been taking doxazosin (Cardura). He says, "I'm not going to take these drugs anymore, because they're interfering with my sex life." Select the nurse's best response
a. "It's unfortunate that these drugs can cause erectile dysfunction, but managing your blood pressure is more important than your sexual performance." b. "I understand how discouraging it must be to live with this side effect, but you could have a stroke if you don't take your blood pressure drugs." c. "Let's discuss this effect with your health care provider. There are other alpha adrenergic blockers and also drugs available to manage this side effect." d. "I'm glad you told me about your experience with this side effect. Sexual per-formance can be a difficult subject to discuss."
Which does the nurse use to complete a general assessment of a toddler efficiently?
1. The nurse avoids waking the child. 2. The child handles some equipment. 3. The parent or guardian is not present. 4. The nurse palpates and then observes.