Nokea
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
You may also like to solve these questions
The nurse is caring for a client with a history of hyperthyroidism.
- A. Which assessment finding is expected in a client with untreated hyperthyroidism?
- B. Bradycardia and weight gain.
- C. Tremors and heat intolerance.
- D. Fatigue and cold intolerance.
- E. Constipation and dry skin.
Correct Answer: B
Rationale: Tremors and heat intolerance are classic symptoms of hyperthyroidism due to increased metabolism. Bradycardia, weight gain, fatigue, and constipation are associated with hypothyroidism.
The nurse is caring for a client with a history of tuberculosis.
- A. Which precaution is most appropriate for a client with active tuberculosis?
- B. Standard precautions.
- C. Droplet precautions.
- D. Contact precautions.
- E. Airborne precautions.
Correct Answer: D
Rationale: Airborne precautions are required for active tuberculosis to prevent transmission via respiratory droplets. Standard, droplet, and contact precautions are insufficient.
A child with epiglottitis.
Which of the following nursing observations would indicate to the nurse that a child with epiglottitis is having an early complication of hypoxemia?
- A. Heart rate of 148 beats per minute.
- B. Bluish discoloration of the skin.
- C. Bluish discoloration around the mouth.
- D. Difficulty swallowing.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to epiglottitis. (1) correct-heart rate correlates with hypoxemia and is an early finding, along with restlessness (2) cyanosis, late sign (3) circumoral cyanosis, late sign (4) sign of epiglottitis
The nurse is caring for a client with a history of asthma who is receiving albuterol via nebulizer. Which of the following findings should the nurse report immediately?
- A. Heart rate of 120 bpm.
- B. Respiratory rate of 20 breaths/min.
- C. Oxygen saturation of 95%.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: A
Rationale: A heart rate of 120 bpm suggests tachycardia, a serious albuterol side effect. Options B, C, and D are normal or expected.
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.