A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take?
1. Perform the assessment from head to toe.
2. Leave intrusive procedures such as ear and eye examinations until the end.
3. Explain each part of the examination to the child before performing it.
4. Ask the mother to tell the child not to be afraid.
Correct Answer: 2
Rationale: 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 includes the heart and lungs.
You might also like to view...
The nurse teaches a client with genital herpes about effective comfort measures. Which statement by the client indicates a need for further teaching by the nurse?
a. "I can apply warm towels or ice packs to the lesions." b. "Sitz baths three times a day may help ease the pain." c. "I understand there are anesthetic sprays and ointments." d. "I really should try to limit urination due to the pain."
The nurse is assessing the client's neurologic system. The nurse tests the client's ability to perform stereognosis. Which of the following activities will accurately test this?
1. The nurse places a vibrating tuning fork over the client's ankle and asks the client to indicate when the vibration can no longer be felt. 2. The nurse asks the client to close her eyes and writes the number 7 in the client's palm with the base of the nurse's pen. The nurse asks the client to identify what was written. 3. The nurse asks the client to close her eyes and places a pen in the client's hand. The nurse asks the client to name the object in her hand. 4. The nurse asks the client to close her eyes and indicate where the nurse is touching the client.
Which information will the nurse collect to assist in the classification of a burn injury as minor, moderate, or major? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Location of the burns on the body 2. The history of the event and location where the injury occurred 3. Any concurrent injuries 4. The time the injury occurred 5. The causative agent
Which of the following is not a non-physiological cause of undernutrition in older people?
a. Wealth. b. Inability to shop. c. Social isolation. d. Inability to prepare and cook meals.