A nurse is planning to assess a 10 month-old infant and bases the assessment on which rationale?
Begin with taking all the vital signs.
Use the Faces scale to rate their pain
Start with less intrusive methods.
Be systematic and go in head to toe order.
The Correct Answer is C
A. Begin with taking all the vital signs.
This is not the preferred approach for assessing a 10-month-old infant. Vital signs may be intimidating and intrusive, and starting with less invasive methods is generally recommended.
B. Use the Faces scale to rate their pain.
The Faces scale is typically used for older children who can express themselves verbally. It may not be suitable for a 10-month-old infant.
C. Start with less intrusive methods.
This is the correct choice. Beginning with less intrusive methods, such as observation and gentle interactions, helps build trust and ensures the infant is comfortable during the assessment.
D. Be systematic and go in a head-to-toe order.
While being systematic is important, starting with less intrusive methods and adapting the approach based on the infant's response is generally more appropriate than a strict head-to-toe order.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "This is common for teens to threaten suicide when they want attention."
This statement is dismissive and could contribute to a lack of appropriate intervention. It is essential not to trivialize or assume that all suicide threats are attention-seeking, as they may indicate underlying distress and a need for support.
B. "Your friend's threat needs to be taken seriously and immediate help for your friend is important."
This is the most appropriate response. It acknowledges the seriousness of the situation, emphasizes the need for immediate help, and reflects a responsible and caring approach to addressing a friend's mention of suicide.
C. "If your friend mentions suicide a second time, you will want to get your friend some help."
Waiting for a second mention is not appropriate, as any mention of suicide should be treated seriously. Delaying intervention until a second mention could be dangerous, as the friend may be in immediate distress.
D. "You need to gather details about your friend's suicide plan."
While gathering information about a friend's thoughts and plans is important for a comprehensive assessment, it is not the primary concern in the immediate response to a suicide mention. The immediate focus should be on ensuring the friend's safety and involving appropriate professionals for help.
Correct Answer is A
Explanation
A. 21 pounds: This is the correct answer. The general guideline is that infants tend to triple their birth weight by the age of 12 months. If the infant weighed 7 pounds at birth, tripling that weight would be 21 pounds.
B. 14 pounds: This weight would not be consistent with the expected weight gain of a healthy infant by 12 months. It's too low based on the tripling guideline.
C. 25 pounds: This weight would be higher than expected based on the tripling guideline. It's not a typical weight for a healthy 12-month-old who had a birth weight of 7 pounds.
D. 10 pounds: This weight would be lower than the expected weight gain. A 12-month-old who started at 7 pounds should have gained more weight by this age.
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