Nokea
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?
- A. Allow her to wear her underpants.
- B. Discuss with her mother why this is important to the child.
- C. Ask her mother to explain to her why she cannot wear them.
- D. Explain in a kind, matter-of-fact manner that this is hospital policy.
Correct Answer: A
Rationale: Allowing the child to keep her underpants on provides a sense of control and comfort, and they can be removed later if needed for anesthesia. Discussing with the mother or citing hospital policy doesn?t address the child?s distress, and asking the mother to explain may escalate the situation.
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A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond?
- A. Holding your child is unsafe.
- B. Holding may help your child relax.
- C. Hospital policy prohibits this interaction.
- D. Holding your child is unnecessary given the childs age.
Correct Answer: B
Rationale: Allowing the mother to hold the child, after assessing safety and familiarity with the procedure, can help the child relax, respecting her preference. Claiming it?s unsafe or against policy is incorrect if family-centered care is supported, and dismissing the need ignores the child?s comfort.
An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurses response is best?
- A. Restraints need to be kept on all the time.
- B. That is fine as long as you are with him.
- C. That is fine if we have his parents consent.
- D. The restraints can be off only when the nursing staff is present.
Correct Answer: B
Rationale: Removing restraints when a responsible adult, like the grandmother, is present to supervise protects the IV site while promoting comfort. Keeping restraints on constantly, requiring parental consent, or limiting removal to staff presence is overly restrictive.
The nurse gives an injection in a patients room. How should the nurse dispose of the needle?
- A. Remove the needle from the syringe and dispose of it in a proper container.
- B. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.
- C. Close the safety cover on the needle and return it to the medication preparation area for proper disposal.
- D. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room.
Correct Answer: B
Rationale: Disposing of the syringe and needle in a rigid, puncture-resistant container in the patient?s room ensures safe, immediate disposal near the point of use. Removing the needle, transporting it, or disposing outside the room increases risk of injury or contamination.
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?
- A. Give him a large cup with ice so it tastes better.
- B. Restrict him to his room until he drinks the GoLYTELY.
- C. Use little cups and make a game to reward him for each cup he drinks.
- D. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
Correct Answer: C
Rationale: Using small cups and making a game with rewards makes the large volume of GoLYTELY less daunting and encourages compliance. A large cup with ice increases the volume, restriction is punitive, and threats about the practitioner are ineffective and inappropriate.
The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation?
- A. Tell him that this procedure will help him get well faster.
- B. Take his blood pressure when a parent is there to comfort him.
- C. Explain to him how the blood flows through the arm and why the blood pressure is important.
- D. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place.
Correct Answer: D
Rationale: Allowing a preschooler to handle the blood pressure equipment and see the cuff in action reduces fear of bodily harm by familiarizing him with the procedure. Explaining complex blood flow is too advanced, claiming it aids recovery is inaccurate, and while parental presence helps, it?s less effective than hands-on engagement.