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

A.

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

B.

Use the bell stethoscope to auscultate breath sounds.

C.

Check visual acuity by using the tumbling E eyechart.

D.

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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Related Questions

Correct Answer is A

Explanation

A. "Your baby's crying is a way to communicate with you." Correct. This response validates the parent's concern and provides an understanding that crying is a normal behaviour for infants as a form of communication.

B. "Why do you feel like your baby cries a lot?" This question might make the parent feel defensive and does not provide reassurance or helpful information about infant behaviour.

C. "Is it possible that you have spoiled your baby?" This response is inappropriate and can make the parent feel judged or blamed. It also suggests a misunderstanding of infant development, as infants cannot be spoiled by responding to their needs.

D. "Letting your baby cry will teach them how to self-soothe." This advice is not suitable for a 1-month-old infant, as they are too young to self-soothe and need their caregivers to respond to their needs for comfort and care.

Correct Answer is ["0.6"]

Explanation

Convert weight from pounds to kilograms:

    • 55 lb / 2.2 lb/kg = 25 kg

Calculate the total milligrams of diphenhydramine needed:

    • Dose (mg/kg) x Weight (kg) = Total milligrams
    • 1.25 mg/kg x 25 kg = 31.25 mg (round to 31.3 mg)

Determine the volume of diphenhydramine solution needed:

    • Total milligrams / Concentration (mg/mL) = Volume (mL)
    • 31.3 mg / 50 mg/mL = 0.63 mL (round to nearest tenth)

Therefore, the nurse should administer 0.6 mL of diphenhydramine 50 mg/mL

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