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.
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Related Questions
Correct Answer is D
Explanation
A. Ask a Buddhist priest to visit.
While spiritual and cultural support can be beneficial, the immediate concern raised by the father is related to dietary preferences. Requesting a visit from a Buddhist priest may not directly address the issue of providing a suitable diet for the child.
B. Explain that hospital patients are exempt from dietary rules.
This approach may not be well-received, as it could be perceived as dismissive of the family's cultural and religious beliefs. It's important to respect and accommodate the family's dietary preferences whenever possible.
C. Help the parent understand that meat provides protein needed for healing.
While nutritional education is valuable, it should be presented in a way that respects the family's beliefs. It's important to acknowledge and accommodate the family's vegetarian preferences while exploring alternative sources of protein.
D. Order the child a meatless tray.
This is the most appropriate intervention in this situation. Ordering a meatless tray respects the family's dietary preferences and ensures that the child's nutritional needs are met within the context of their cultural and religious beliefs.
Correct Answer is ["A","B","C"]
Explanation
A. Respirations: Monitoring respiratory rate and pattern is crucial when a child is receiving narcotics, as these medications can depress the respiratory system. Rapid or shallow breathing may indicate respiratory distress.
B. Level of consciousness: This is important to assess for any signs of sedation or altered mental status, which can be a side effect of narcotics.
C. Oxygen saturations: Monitoring oxygen saturations is essential, especially if there are concerns about respiratory depression. A decrease in oxygen saturations could indicate inadequate ventilation.
D. Bowel sounds: While bowel sounds are important to assess for gastrointestinal function, they are not the top priority when monitoring a child receiving narcotics. Respiratory and central nervous system status take precedence.
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