Nokea
A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?
- A. Use an 18-gauge needle if possible.
- B. Show the child the equipment to be used before the procedure.
- C. If not successful after four attempts, have another nurse try.
- D. Restrain the child completely.
Correct Answer: B
Rationale: Showing the child the equipment before the procedure reduces fear and supports atraumatic care. An 18-gauge needle is too large, a two-try policy (four attempts total) is preferred, and full restraint is unnecessary, favoring therapeutic hugging instead.
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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 is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?
- A. Explain that it will not be painful.
- B. Suggest to him that he not worry about losing just a little bit of blood.
- C. Discuss with him how his body is always in the process of making blood.
- D. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
Correct Answer: C
Rationale: Explaining that the body continuously makes blood addresses the child?s fear of loss using age-appropriate scientific terms. Claiming it won?t hurt is inaccurate, dismissing worry doesn?t reassure, and minimizing the need for a Band-Aid trivializes the child?s concern.
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen?
- A. Establish a contract with her, including rewards.
- B. Suggest time-outs when she forgets her medicine.
- C. Discuss with her mother the damaging effects of her rescuing the child.
- D. Ask the child to bring her medicine containers to each appointment so they can be counted.
Correct Answer: A
Rationale: Establishing a behavioral contract with rewards encourages adherence by addressing barriers like side effects or scheduling and motivates the child. Time-outs are punitive, discussing maternal rescuing is less effective, and checking containers monitors but doesn?t promote self-responsibility.
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do?
- A. Set up a tray with equipment the same size as for adults.
- B. Apply EMLA to the puncture site 15 minutes before the procedure.
- C. Prepare the child for conscious sedation being used for the procedure.
- D. Reassure the parents that the test is simple, painless, and risk free.
Correct Answer: C
Rationale: Conscious sedation is appropriate for a lumbar puncture in a 2-year-old with suspected bacterial meningitis due to the procedure?s urgency and need for cooperation. Adult-sized equipment is inappropriate, EMLA requires 60 minutes, and claiming the procedure is simple or painless is misleading.
A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child?
- A. Relief of discomfort
- B. Reassurance that illness is temporary
- C. Prevention of secondary bacterial infection
- D. Avoidance of life-threatening complications
Correct Answer: A
Rationale: Treating fever primarily relieves discomfort using antipyretics and environmental measures. It doesn?t reassure temporariness, prevent bacterial infections, or significantly reduce rare complications like febrile seizures.