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. Increased urine output: This is not typically associated with heart failure. In fact, decreased urine output may occur due to reduced kidney perfusion.
B. Weight loss: While weight loss can occur in heart failure, it’s more common in adults than in children. In children, especially toddlers, weight gain or failure to thrive might be observed due to fluid retention or poor nutrition absorption.
C. Bradycardia: This is not typically a sign of heart failure. In heart failure, the heart rate is often increased (tachycardia) as the heart tries to compensate for its decreased pumping efficiency.
D. Orthopnea: This is the correct answer. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure. It occurs because when the body is in a horizontal position, fluid in the body is redistributed, leading to increased fluid in the lungs and difficulty breathing.
Correct Answer is D
Explanation
. Respiratory: While respiratory symptoms can occur in Kawasaki disease, they are not the primary concern.
B. Gastrointestinal: Gastrointestinal symptoms can occur in Kawasaki disease, but they are not the primary concern.
C. Integumentary: Although Kawasaki disease can cause symptoms such as a rash and peeling skin, these are not the primary concerns.
D. Cardiovascular: This is the correct answer. Kawasaki disease can lead to serious complications involving the heart, such as coronary artery aneurysms. Therefore, monitoring the cardiovascular system is crucial in managing this condition.
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