A mother brings her 3-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child'stemperature, which method would be least appropriate?
Tympanic
Oral
Axillary
Rectal
The Correct Answer is D
A. TympaniC. Tympanic temperature measurement using an ear thermometer is a convenient and accurate method for assessing temperature in children, including toddlers.
B. Oral: Oral temperature measurement using a digital thermometer placed under the tongue is a commonly used method for children who can cooperate with the procedure and keep the
thermometer in their mouth.
C. Axillary: Axillary temperature measurement using a thermometer placed in the armpit is a non-invasive method suitable for children who cannot cooperate with oral or tympanic
measurements or when rectal measurement is contraindicated.
D. Rectal: Rectal temperature measurement is generally considered the most accurate method for assessing temperature in infants and young children, especially when accuracy is critical.
However, it may be less appropriate in the emergency department setting due to its invasive nature and potential discomfort for the child, especially in cases of diarrhea or vomiting where rectal temperature measurement may be difficult or impractical.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Tell me about the circumstances when this occurs.": This response allows the nurse to gather more information about the child's toileting habits and potential triggers for the accidents.
Understanding the context can help identify possible underlying causes and guide appropriate interventions.
B. "Is there a family history of diabetes?": While diabetes can be a cause of increased urination, asking about a family history of diabetes is premature and may unnecessarily alarm the parent before further assessment.
C. "Suddenly having accidents can be a sign of diabetes.": Jumping to conclusions about a serious medical condition like diabetes without further assessment or evidence can cause unnecessary anxiety for the parent. It's important to gather more information and consider other potential causes before suggesting a diagnosis.
D. "That's normal: don't worry about it.": While occasional daytime wetting accidents can be common in young children, dismissing the concern without further assessment may overlook potential underlying issues that could benefit from intervention or support.
Correct Answer is A
Explanation
A. Tell the child that another child the same age wasn't afraiD. This approach may backfire as toddlers may not fully understand or relate to the concept of comparison with other children. Additionally, it could potentially increase the child's anxiety by implying that being afraid is abnormal.
B. Permit the child to sit on the parent's lap during the examination: Allowing the child to stay close to their caregiver can provide comfort and security, promoting cooperation during the examination.
C. Offer immediate praise for holding still or doing what was askeD. Positive reinforcement can encourage desired behavior and cooperation by reinforcing the child's efforts to comply with the examination process.
D. Allow the child to touch and hold the equipment when possiblE. Giving the child a sense of control and familiarity with the examination tools can help alleviate fear and increase cooperation during the examination.
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