Nokea
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.
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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 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.
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.
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.
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source?
- A. Herself
- B. Her mother
- C. Court order
- D. Legal guardian
Correct Answer: A
Rationale: Contraceptive advice is considered a medically emancipated condition, allowing the 16-year-old to provide her own informed consent. Parental or guardian consent is not required, and a court order is unnecessary for this routine care.