Nokea
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.
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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.
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?
- A. Febrile seizures can result.
- B. Antipyretics may cause malignant hyperthermia.
- C. Antipyretics are of no value in treating hyperthermia.
- D. Liver damage may occur in critically ill children.
Correct Answer: C
Rationale: Antipyretics are ineffective for hyperthermia, as the body?s temperature set point is normal, requiring cooling measures instead. Seizures are linked to fever, not hyperthermia; malignant hyperthermia is unrelated to antipyretics; and while liver damage is a risk with acetaminophen, it?s not the primary reason.
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.
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.
Using knowledge of child development, what approach is best when preparing a toddler for a procedure?
- A. Avoid asking the child to make choices.
- B. Plan for a teaching session to last about 20 minutes.
- C. Demonstrate on a doll how the procedure will be done.
- D. Show the necessary equipment without allowing child to handle it.
Correct Answer: C
Rationale: Demonstrating the procedure on a doll engages a toddler?s preoperational thinking through play, reducing fear. Avoiding choices limits participation, 20-minute sessions are too long for a toddler?s attention span, and showing equipment without handling increases anxiety.