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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A temperature of 37.2°C (99°F) is slightly elevated but not a major concern post-surgery.
B. Urine output 256 mL over 8 hr: In a child with nephrotic syndrome, adequate urine output is crucial. For a child weighing 12 kg, an output of around 30 mL/hr (or 240 mL over 8 hours) is considered normal. 256 mL over 8 hr indicates adequate urine production
C. No pain with voiding is a positive sign but doesn't necessarily indicate overall effectiveness of treatment for nephrotic syndrome.
D. Odourless urine is a normal finding and not necessarily an indicator of treatment success.
Correct Answer is B
Explanation
A. Soak combs and brushes in boiling water for 10 min. Incorrect. While cleaning items is important, soaking combs and brushes in boiling water is more relevant to head lice, not scabies. Scabies mites live on skin and are unlikely to infest combs and brushes.
B. Treat everyone who came into close contact with the child. Correct. Scabies is highly contagious and spreads through close personal contact. All household members and close contacts should be treated simultaneously to prevent reinfestation.
C. Apply petroleum jelly to the affected areas. Incorrect. The treatment for scabies involves prescription scabicides (such as permethrin cream), not petroleum jelly.
D. Wash the child's hair with shampoo containing ketoconazole. Incorrect. Ketoconazole shampoo is used for fungal infections like dandruff or seborrheic dermatitis, not scabies.
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