A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?
"I am going to listen to your heart."
"Can I listen to your lungs?"
"I am going to take your blood pressure now."
"Can you stand very still while I feel how warm you are?"
The Correct Answer is A
A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Place the child in an upright position: This is the correct answer. Sitting upright can help make breathing easier for a child with epiglottitis.
B. Transport the child to radiology for a throat x-ray: While an x-ray can confirm the diagnosis, it should only be done under the supervision of a healthcare provider due to the risk of airway obstruction.
C. Obtain a throat culture: This is not typically done in suspected cases of epiglottitis because it could trigger a spasm and cause airway obstruction.
D. Visualize the epiglottis with a tongue depressor: This should not be done because it can cause airway obstruction and is potentially life-threatening in a child with suspected epiglottitis.
Correct Answer is A
Explanation
A. Position the child laterally: This is the correct action. During a seizure, positioning the child on their side (lateral position) can help prevent aspiration of saliva or vomit.
B. Use a padded tongue blade: This is not recommended. Inserting anything into the mouth of a person having a seizure can cause injury to the teeth or jaw.
C. Restrain the child’s arms: This is not recommended. During a seizure, it’s important not to restrain the child as it can lead to injury.
D. Attempt to stop the seizure: This is not possible. Seizures usually need to run their course. It’s important to keep the child safe during the seizure and seek medical attention if necessary.
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