A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?
Give the child a stuffed animal.
Inform the child that her parent will be back in 2 hr.
Call the parent to return to the child's room.
Leave the child alone in the room for 5 min.
The Correct Answer is A
A. Give the child a stuffed animal: Providing a comforting item like a stuffed animal can help the child feel more secure and may offer some comfort during the parent's absence. This option is appropriate as it addresses the child's emotional needs.
B. Inform the child that her parent will be back in 2 hours: While it's helpful to provide reassurance to the child, a 2-year-old may not fully understand the concept of time, and telling them that their parent will return in 2 hours may not effectively alleviate their distress. This option may not be as immediately comforting as providing a tangible source of comfort.
C. Call the parent to return to the child's room: If possible, having the parent return to the child's room can provide the most direct comfort and reassurance to the child during a tantrum. However, it may not always be feasible for the parent to return immediately, especially if they are occupied or attending to other responsibilities.
D. Leave the child alone in the room for 5 minutes: Leaving the child alone during a tantrum can exacerbate feelings of distress and abandonment, potentially escalating the situation further. It's essential to provide support and reassurance to the child during moments of distress rather than leaving them alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Machine-like murmur.
This option is correct. A characteristic clinical manifestation of a large patent ductus arteriosus is a continuous "machine-like" murmur heard on auscultation. This murmur is typically heard best at the upper left sternal border and may radiate to the back.
B. Chronic hypoxemia.
Chronic hypoxemia is not typically a primary manifestation of a large PDA. While PDA can lead to increased pulmonary blood flow and potentially contribute to pulmonary congestion, chronic hypoxemia may not be a prominent feature unless complications such as heart failure develop.
C. Cyanosis with crying.
Cyanosis with crying is more commonly associated with cyanotic congenital heart defects such as tetralogy of Fallot. While PDA can contribute to cyanosis in certain circumstances, it is not typically a consistent clinical manifestation.
D. Weak pulse.
A weak pulse is not typically associated specifically with a large PDA. Infants with PDA may have bounding pulses due to increased blood flow through the ductus arteriosus.
Correct Answer is C
Explanation
A. Overriding aorta: In Tetralogy of Fallot, the aorta is positioned over the ventricular septal defect (VSD), rather than solely over the left ventricle as it would be in a normal heart. This is called overriding aorta, which allows blood from both the right and left ventricles to enter the aorta.
B. Pulmonary stenosis: This is a critical component of Tetralogy of Fallot. Pulmonary stenosis refers to narrowing of the pulmonary valve or the area just below it, which restricts blood flow from the right ventricle to the pulmonary artery. This results in decreased blood flow to the lungs for oxygenation.
C. Left ventricular hypertrophy: This choice is not typically associated with Tetralogy of Fallot. Left ventricular hypertrophy refers to an enlargement or thickening of the muscular wall of the left ventricle of the heart. It is often seen in conditions where the left ventricle has to work harder to pump blood, such as in hypertension or aortic stenosis, but it is not a characteristic feature of Tetralogy of Fallot.
D. Ventricular septal defect: This defect is one of the four components of Tetralogy of Fallot. A ventricular septal defect (VSD) is a hole in the septum, the muscular wall that separates the left and right ventricles of the heart. In Tetralogy of Fallot, the VSD allows oxygen-poor blood from the right ventricle to flow directly into the left ventricle and out to the body.
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