Nokea
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
You may also like to solve these questions
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches
- B. Green drainage
- C. Reddened tissue
- D. Eschar development
Correct Answer: C
Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.
The nurse is providing care to a client with posttraumatic stress disorder following a terrorist attack at the client's place of worship. The client says, 'I'm just so worried all the time. I will never be safe again!' What is the priority nursing action?
- A. Acknowledge the client's feelings
- B. Assess the client's support system
- C. Encourage the client to talk about the trauma
- D. Offer the client a PRN sleep medication
Correct Answer: A
Rationale: Acknowledging feelings (A) builds trust and validates the client's experience, making it the priority. Assessing support (B), discussing trauma (C), or offering medication (D) are secondary.
The nurse is inserting an indwelling urinary catheter for a male client. After inserting the catheter 6 inches (15.2 cm), the nurse notes a small amount of urine in the tubing. Which of the following actions should the nurse take next?
- A. Measure the urine output.
- B. Immediately inflate the balloon.
- C. Secure the catheter tubing to the client's leg.
- D. Continue to advance the catheter to the bifurcation.
Correct Answer: D
Rationale: Advancing to the bifurcation (D) ensures proper placement in the bladder before inflating the balloon. Measuring output (A), inflating early (B), or securing (C) are premature.
A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?
- A. Assign different staff members to care for the client each day
- B. Assign the client's stated preferred nurse to care for the client
- C. Reassure the client that all staff members are competent in their jobs
- D. Reinforce unit guidelines and appropriate boundaries with the client
Correct Answer: D
Rationale: Reinforcing boundaries (D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (A), assigning the preferred nurse (B), or reassuring competence (C) may reinforce manipulation.
The nurse is assisting the physician with an examination of a client with Addison's disease. During the examination, the nurse will note which change in the client's integumentary system?
- A. Edema of the hands and feet
- B. Hirsutism
- C. Bronze pigmentation
- D. Pendulous abdomen
Correct Answer: C
Rationale: Addison's disease causes bronze pigmentation due to increased ACTH. Edema , hirsutism , and pendulous abdomen are not typical.