A nurse is preparing to collect data from a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply.)

Answers questions asked by the nurse

Plays with toys in the examining room

Makes eye contact with the nurse

Allows the nurse to touch him on the arm

Sits on his parent's lap when the nurse enters the room

Answer and Explanation

Correct Answer : A,C,D

A. Answers questions asked by the nurse: Responding verbally shows the child is engaged and able to understand and participate in the interaction, indicating readiness to cooperate during the assessment.

B. Plays with toys in the examining room: While playing indicates comfort in the environment, it may also reflect distraction or avoidance rather than readiness to cooperate with the nurse’s instructions. Play alone is not a reliable indicator of cooperation.

C. Makes eye contact with the nurse: Eye contact demonstrates attention and willingness to engage with the nurse, which is a positive sign that the child is prepared to follow directions during data collection.

D. Allows the nurse to touch him on the arm: Tolerating touch shows trust and comfort with the nurse’s presence and interventions, signaling the child is ready to participate in the assessment.

E. Sits on his parent's lap when the nurse enters the room: Sitting on a parent’s lap may indicate the child is seeking comfort and security rather than being ready to cooperate independently. This behavior alone does not confirm readiness for assessment.

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Correct Answer is ["A","B","E"]

Explanation

A. Respiratory rate: A respiratory rate of 30 breaths per minute indicates significant respiratory distress. Labored breathing combined with crackles and wheezes suggests impaired gas exchange and possible lower respiratory infection requiring urgent intervention.

B. Oxygen saturation level: An oxygen saturation of 89% on room air reflects hypoxemia. Reduced oxygen levels place the client at risk for tissue hypoxia and worsening respiratory failure, making prompt follow-up and oxygen therapy necessary.

C. Chronic health condition: A history of smoking, Parkinson’s disease, and anxiety increases overall health risk but does not explain the acute deterioration. Chronic conditions provide context but are not the immediate priority compared with current unstable findings.

D. Tremors: Hand tremors are consistent with Parkinson’s disease and may also be worsened by anxiety or illness. Tremors alone do not pose an immediate life-threatening risk in this situation.

E. Current level of consciousness: Orientation only to self and failure to follow commands suggest acute changes in mental status. Altered cognition in an older adult with fever and hypoxia may indicate delirium or worsening infection and requires immediate evaluation.

F. Heart rate: A heart rate of 104 beats per minute indicates mild tachycardia, likely related to fever or hypoxia. Although important to monitor, it is less immediately threatening than hypoxemia, tachypnea, and altered mental status.

A. A nurse from another unit after a client commits suicide B. A client's employer who is concerned about safety due to substance use C. A client's partner after the client reports intimate partner abuse D. A social worker who is assigned to an involuntarily committed school-age client

Correct Answer is D

Explanation

A. A nurse from another unit after a client commits suicide: Sharing confidential client information with staff not directly involved in the client’s care is a violation of privacy, even in the event of suicide. Only those providing care or requiring information for safety or treatment purposes should have access.

B. A client's employer who is concerned about safety due to substance use: Client health information cannot be shared with an employer without the client’s written consent, as this breaches confidentiality and HIPAA regulations. Employer concerns do not override the client’s right to privacy.

C. A client's partner after the client reports intimate partner abuse: Confidentiality must be maintained even in cases of abuse. Information should not be disclosed to a partner, as this could endanger the client further. Disclosure requires the client’s consent or legal mandate.

D. A social worker who is assigned to an involuntarily committed school-age client: Sharing relevant medical information with the social worker who is part of the client’s care team is appropriate. This ensures continuity of care, safety, and coordination of services while maintaining confidentiality within the care team.

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A nurse is preparing to collect data from a preschooler. Which of the following behaviors by the child indicates that he is ready to cooperate? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of an older adult client who was admitted from a long-term care facility. Select the 3 findings that require immediate follow-up.

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Explanation

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Correct Answer is D

Explanation

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