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 D
Explanation
A. “Burp your baby more frequently during feedings”: While burping can help with minor feeding issues, it’s unlikely to resolve the issue of projectile vomiting after eating.
B. “Try switching to a different formula”: While this might be an option in some cases, it’s not the first step to take. Projectile vomiting can be a sign of a more serious condition, such as pyloric stenosis, which needs medical attention.
C. “Give your infant an oral rehydration solution”: While rehydration is important, especially if the baby is vomiting, it doesn’t address the underlying issue causing the vomiting.
D. “Bring your baby in to the clinic today”: This is the correct action. Projectile vomiting in an infant, especially when combined with increased hunger, is a concern and should be evaluated by a healthcare professional as soon as possible
Correct Answer is D
Explanation
A. Pain when manipulating the affected ear lobe: While this can be a symptom of otitis externa (an infection of the outer ear), it is not typically associated with otitis media, which is an infection of the middle ear.
B. Erythema and edema of the affected ear: These are more commonly associated with otitis externa or an ear injury, not otitis media.
C. Clear drainage from the affected ear: This could indicate a ruptured eardrum, which can occur with severe or untreated otitis media, but it is not a typical symptom.
D. Tugging on the affected ear lobe: This is the correct answer. Children with otitis media often tug or pull at their ears due to the pain and discomfort caused by the infection. This is a common symptom of otitis media.
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