A nurse is preparing to perform a physical assessment on a 20-month-old toddler who is initially uncooperative and anxious. Which approach should the nurse prioritize to facilitate an effective and less distressing assessment?
Perform all intrusive procedures first to get them over with quickly, minimizing total assessment time.
Remove all clothing at once to speed up the process and avoid repeated exposure that may upset the toddler.
Allow the toddler to sit in the parent's lap and examine the least invasive areas first, offering simple choices and praise to encourage cooperation.
Start the examination with the toddler on the exam table immediately to establish control over the assessment environment.
The Correct Answer is C
A. Performing all intrusive procedures first is incorrect because starting with invasive or uncomfortable procedures can cause significant anxiety and fear in a toddler. This approach often results in the child resisting further assessment, making it more difficult to complete the exam accurately and safely. Toddlers respond better when trust is gradually built, and starting with procedures that are frightening can interfere with cooperation.
B. Removing all clothing at once is incorrect because toddlers often feel vulnerable and frightened when fully exposed. Gradual undressing allows the child to maintain a sense of security and modesty. Keeping parts of the body covered until each area is assessed helps minimize distress, making the assessment smoother and safer for both the child and the nurse.
C. Allowing the toddler to sit in the parent's lap and examining the least invasive areas first is correct. This approach provides comfort and reassurance through physical proximity to the parent, which helps the toddler feel safe. Starting with non-threatening areas, such as observing the child’s general appearance or auscultating the heart and lungs, builds trust and reduces anxiety. Offering simple choices, such as letting the child choose which arm to examine first, gives the toddler a sense of control and autonomy. Praise and positive reinforcement further encourage cooperation, making the examination more effective and less stressful. This approach aligns with developmentally appropriate care for toddlers, emphasizing safety, emotional support, and gradual progression from non-invasive to more invasive procedures.
D. Starting the examination with the toddler on the exam table immediately is incorrect because forcing the child to separate from the parent can increase anxiety and resistance. Toddlers are more cooperative when they feel secure, so placing them directly on an exam table without parental support can lead to distress, crying, and possible refusal to participate, which may compromise the quality and safety of the assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The mother begins to take on a more independent role and discusses her expectations for future parenting is incorrect because this behavior is more characteristic of the letting-go phase, when the mother moves beyond self-focus and embraces her new parental role.
B. The mother focuses on taking care of her baby and begins to establish a routine is incorrect because this behavior aligns with the taking-hold phase, when the mother becomes more actively involved in infant care and develops confidence in her maternal role.
C. The mother starts to exhibit confidence in her ability to care for the baby and takes charge of household responsibilities is incorrect because this also reflects the taking-hold phase, where independence and competence in caregiving become evident.
D. The mother is primarily focused on her own recovery and needs is correct because the taking-in phase occurs during the first 24–48 hours postpartum. During this phase, the mother is passive, dependent, and preoccupied with her own physical comfort and recovery, often reflecting on the birth experience. She may be reluctant to make decisions about the infant, needing guidance and support from healthcare providers.
Correct Answer is B
Explanation
A. Administering pain medications to relieve headache and muscle aches is important for comfort, but it is not the highest priority during the induction phase.
B. Monitoring for signs of infection due to neutropenia is correct because induction chemotherapy causes profound bone marrow suppression, leading to neutropenia. Neutropenia significantly increases the risk of infection, which can become life-threatening. Early detection of fever, chills, or other infection signs is critical for timely intervention, making infection prevention and monitoring the top priority during this phase.
C. Recommending home-schooling to minimize exposure to other children is supportive and helpful for infection prevention but is secondary to direct monitoring and management of neutropenia.
D. Encouraging a high-protein diet to promote growth is beneficial for overall health and recovery but is not the primary concern during the induction phase, when preventing infection is life-saving.
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