A nurse is performing a physical assessment for a preschooler. Which of the following actions should the nurse take?

Auscultate the abdomen for at least 1 min if bowel sounds are absent.

Use the bell stethoscope to auscultate breath sounds.

Check visual acuity by using the tumbling E eyechart.

Place hand on the preschooler's abdomen to determine respiratory rate.

Answer and Explanation

The Correct Answer is C

A. Auscultate the abdomen for at least 1 min if bowel sounds are absent. This is an appropriate action. Absence of bowel sounds can indicate a serious condition, so the nurse should auscultate for at least 1 minute to confirm their absence. However, it is generally recommended to listen for up to 5 minutes before concluding that bowel sounds are absent.

B. Use the bell stethoscope to auscultate breath sounds. The diaphragm of the stethoscope, not the bell, is typically used to auscultate breath sounds because it is better at picking up higher-pitched sounds like those of the lungs.

C. Check visual acuity by using the tumbling E eyechart. The tumbling E chart is appropriate for pre-schoolers who may not know the alphabet. This chart helps assess visual acuity in young children by having them identify the direction of the E's legs.

D. Place hand on the pre-schooler’s abdomen to determine respiratory rate. Placing a hand on the abdomen can help in counting the respiratory rate in infants and very young children who are diaphragmatic breathers, but for pre-schoolers, it is typically easier and more accurate to count respirations by observing the chest rise.

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Correct Answer is C

Explanation

A. Tea tree: Tea tree oil is known for its antimicrobial properties and is commonly used for skin issues such as acne or fungal infections. It is not typically recommended for relaxation purposes.

B. Eucalyptus: Eucalyptus oil is often used for its respiratory benefits, such as easing congestion and colds. It is stimulating rather than calming and is not commonly recommended for relaxation.

C. Lavender: Lavender oil is widely recognized for its calming and relaxing properties. It is often used to help reduce anxiety, promote relaxation, and improve sleep quality.

D. Jasmine: Jasmine oil is known for its uplifting and energizing properties rather than relaxing. While it has a pleasant scent and can have mood-enhancing effects, it is not specifically recommended for relaxation.

A. Mix the medication with the child's favorite food. B. Dilute the medication with 8 oz of water. C. Provide an ice pop after administering the medication. D. Give 4 oz of milk with the medication.

Correct Answer is C

Explanation

a. Mix the medication with the child's favorite food. Mixing medication with a child’s favorite food can be risky as it may alter the taste of the food and cause the child to develop an aversion to that food. Additionally, if the child does not consume the entire portion, they may not receive the full dose of medication.

b. Dilute the medication with 8 oz of water. Diluting medication in a large volume of water is not advisable for a preschooler as it may be difficult for them to drink the entire amount, leading to an incomplete dose. It can also dilute the medication to the point where its efficacy is reduced.

c. Provide an ice pop after administering the medication. Offering an ice pop after administering the medication is a positive reinforcement technique. The ice pop can also help numb the taste buds, reducing the aftertaste of the medication, making it more acceptable for the child.

d. Give 4 oz of milk with the medication.Giving milk with medication is not generally recommended as it can interfere with the absorption of some medications. Additionally, if the medication tastes unpleasant, the child might refuse to drink the milk as well.

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A nurse is performing a physical assessment for a preschooler. Which of the following actions should the nurse take?

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