A 4-year-old begins to cry when his mother tells him it is time for his operation. The nurse understands this is an expected reaction because the preschooler is particularly fearful of:
Invasive procedures.
Unfamiliar routines.
Loss of control.
Restricted mobility
The Correct Answer is C
Preschool children (ages 3–6) are in Erikson’s stage of initiative vs guilt, where hospitalization commonly triggers anxiety due to perceived threats to autonomy, unfamiliar separation from caregivers, and misunderstanding of medical procedures.
Rationale:
A. Fear of invasive procedures is more characteristic of older children who can cognitively understand bodily harm. Preschoolers may react to procedures, but their dominant developmental fear is not procedural invasiveness but psychological autonomy disruption.
B. Unfamiliar routines contribute to anxiety but are not the primary developmental fear. Preschoolers adapt to routines through repetition; however, their main distress stems from perceived restriction of independence and control rather than routine unfamiliarity alone.
C. Loss of control is the central fear in preschoolers due to their developing autonomy. Hospitalization restricts choices, separates them from caregivers, and imposes authority, leading to distress, crying, and resistance when faced with procedures like surgery.
D. Restricted mobility may cause frustration, but it is secondary. Preschoolers may not fully conceptualize immobility as the primary threat. Their emotional response is more strongly driven by perceived loss of independence and inability to direct their own actions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Peripheral intravenous therapy in pediatric patients requires frequent monitoring due to higher risk of infiltration, phlebitis, infection, and fluid overload. Children have smaller and more fragile veins, making IV sites more prone to rapid deterioration and complications. Continuous infusions demand close surveillance to ensure patency and prevent tissue injury or systemic complications.
Rationale:
A. This interval is too prolonged for pediatric IV monitoring. Delayed assessment increases risk of unrecognized infiltration or extravasation, which can rapidly cause tissue damage in children due to small vessel size and limited subcutaneous space.
B. Pediatric continuous IV infusions require hourly site assessment to detect early signs of infiltration, phlebitis, or dislodgement. Frequent monitoring ensures immediate intervention, minimizing complications and maintaining safe vascular access.
C. This frequency is appropriate for stable adult IV sites but unsafe in pediatrics. Extended intervals increase risk of missed complications, especially with continuous infusions where tissue damage can progress quickly in children.
D. Although closer to acceptable practice, this interval is still insufficient for high-risk pediatric infusions. Early detection of complications is critical, and standard pediatric protocols favor more frequent hourly assessments.
Correct Answer is B
Explanation
Rapid elevation of body temperature in infants and young children can trigger febrile seizures due to immature central nervous system thermoregulation, increased neuronal excitability, and lowered seizure threshold during febrile illness, especially with abrupt temperature rise above 38.9°C.
Rationale:
A. Lethargy is a nonspecific symptom of systemic infection or fever but is not a direct acute complication of rapid temperature rise. It reflects reduced energy and illness severity rather than a neurologically mediated emergency event.
B. Febrile seizures occur due to rapid temperature elevation affecting neuronal excitability in the immature brain. The sudden rise increases metabolic demand and alters ion channel function, lowering seizure threshold, particularly in children aged 6 months to 5 years.
C. Tachycardia is a physiological compensatory response to fever rather than a complication. Increased heart rate helps meet metabolic demands during pyrexia but does not represent a direct neurologic or acute febrile complication like seizure activity.
D. Hypertension is not typically associated with febrile responses in infants. Fever more commonly causes vasodilation and potential hypotension in severe cases. Elevated blood pressure is not a recognized complication of rapid temperature rise in pediatric patients.
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