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.
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Related Questions
Correct Answer is B
Explanation
A. Perform chest physiotherapy: This is typically used for clients with respiratory conditions that cause mucus to build up in the lungs, not for preventing aspiration in a post-tonsillectomy client.
B. Withhold fluids until the client demonstrates a gag reflex: This is the correct answer. After a tonsillectomy, the client’s throat may be numb from local anesthetics, and they may not have a fully functioning gag reflex. Giving fluids before the gag reflex returns could lead to aspiration.
C. Suction the nasopharynx as needed: While suctioning can help clear the airway, it’s not typically done routinely after a tonsillectomy unless the client is having difficulty clearing secretions on their own.
D. Place a bedside humidifier at the head of the client’s bed: While this can help soothe a sore throat after a tonsillectomy, it won’t necessarily prevent aspiration. It’s more important to ensure the client’s gag reflex has returned before giving fluids.
Correct Answer is B
Explanation
A. Osteosarcoma: This is a type of bone cancer that often occurs in teenagers and young adults, but it’s not the most common malignant renal and intra-abdominal tumor of childhood.
B. Wilms’ tumor: This is the correct answer. Wilms’ tumor, also known as nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood. It typically occurs in children aged 3 to 4 years.
C. Neuroblastoma: This is a type of cancer that often starts in the adrenal glands, which are on top of the kidneys. It can also develop in nerve tissue along the spine, chest, abdomen, or pelvis. While it is common in infants and young children, it’s not the most common malignant renal and intra-abdominal tumor of childhood.
D. Ewing sarcoma: This is a rare type of cancer that occurs in bones or in the soft tissue around the bones. It’s more common in teenagers and young adults, and it’s not the most common malignant renal and intra-abdominal tumor of childhood.
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