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When the nurse interviews an adolescent, which is especially important?
- A. Focus the discussion on the peer group.
- B. Allow an opportunity to express feelings.
- C. Use the same type of language as the adolescent.
- D. Emphasize that confidentiality will always be maintained.
Correct Answer: B
Rationale: Adolescents, like all children, need opportunities to express their feelings. Often they interject feelings into their words. The nurse must be alert to the words and feelings expressed. The nurse should maintain a professional relationship with adolescents. To avoid misunderstanding or misinterpretation of words and phrases used, the nurse should clarify the terms used, what information will be shared with other members of the health care team, and any limits to confidentiality. Although the peer group is important to this age group, the interview should focus on the adolescent.
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The nurses approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle?
- A. The child may think the equipment is alive.
- B. Explaining the equipment will only increase the childs fear.
- C. One brief explanation will be enough to reduce the childs fear.
- D. The child is too young to understand what the equipment does.
Correct Answer: A
Rationale: Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the childs fear. Preschoolers need repeated explanations as reassurance.
During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is which?
- A. A normal finding
- B. A sign of a possible visual defect and a need for vision screening
- C. An abnormal finding requiring referral to an ophthalmologist
- D. A sign of small hemorrhages, which usually resolve spontaneously
Correct Answer: A
Rationale: A brilliant, uniform red reflex is an important normal finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
During an otoscopic examination on an infant, in which direction is the pinna pulled?
- A. Up and back
- B. Up and forward
- C. Down and back
- D. Down and forward
Correct Answer: C
Rationale: In infants and toddlers, the ear canal is curved upward. To visualize the ear canal, it is necessary to pull the pinna down and back to the 6 to 9 oclock range to straighten the canal. In children older than age 3 years and adults, the canal curves downward and forward. The pinna is pulled up and back to the 10 oclock position. Up and forward and down and forward are positions that do not facilitate visualization of the ear canal.
The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
- A. Use the small cuff.
- B. Use the large cuff.
- C. Use either cuff using the palpation method.
- D. Wait to take the blood pressure until a proper cuff can be located.
Correct Answer: B
Rationale: If blood pressure measurement is indicated and the appropriate size cuff is not available, the next larger size is used. The nurse recognizes that this may be a falsely low blood pressure. Using the small cuff will give an incorrectly high reading. The palpation method will not improve the inaccuracy inherent in the cuff.
Which is considered a block to effective communication?
- A. Using silence
- B. Using clichés
- C. Directing the focus
- D. Defining the problem
Correct Answer: B
Rationale: Using stereotyped comments or clichés can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention.