The nurse is assessing a child who is lying quietly on the bed. Which action should the nurse take?
Pick up the child from the environment.
Leave the child in a flexed position on the bed.
Check the child’s level of consciousness and pain scale.
Assume the child is quietly sleeping on the parent’s lap.
The Correct Answer is C
Choice A reason: Picking up the child without assessment risks disrupting a potentially critical condition, as quiet lying may indicate pain or altered consciousness. Checking consciousness and pain ensures safety, making this premature and incorrect compared to prioritizing a thorough evaluation of the child’s quiet state.
Choice B reason: Leaving the child in a flexed position assumes no issue without assessing consciousness or pain, which quiet behavior may mask. Evaluating the child’s status is critical, making this passive and incorrect compared to actively checking for underlying issues in the child’s quiet presentation on the bed.
Choice C reason: Checking the level of consciousness and pain scale determines if the child’s quietness indicates distress, pain, or neurological issues, ensuring appropriate care. This aligns with pediatric assessment protocols, making it the correct action to address the child’s condition lying quietly on the bed.
Choice D reason: Assuming the child is sleeping on the parent’s lap is incorrect, as the child is on the bed, and quietness may indicate distress. Assessing consciousness and pain is essential, making this inaccurate and incorrect compared to evaluating the child’s true condition in this scenario.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Urination frequency varies individually, not by gender, and isn’t a primary UTI risk factor. The shorter female urethra explains higher UTI rates, making this inaccurate and incorrect compared to the anatomical reason for the daughter’s recurrent infections in the 5-year-old twins.
Choice B reason: Assuming poor hygiene without evidence is speculative and less relevant than anatomical differences. The shorter urethra is the primary UTI risk in girls, making this blaming and incorrect compared to explaining the biological factor contributing to the daughter’s infections in the teaching.
Choice C reason: Vitamin C may support urinary health but isn’t gender-specific or a primary UTI cause. The shorter female urethra directly increases contamination risk, making this irrelevant and incorrect compared to the anatomical explanation for the daughter’s recurrent UTIs in the caregiver’s twins.
Choice D reason: Girls’ shorter, straighter urethras allow easier bacterial access to the bladder, explaining higher UTI rates compared to boys. This anatomical fact aligns with pediatric urology evidence, making it the accurate statement to clarify the daughter’s recurrent infections for the caregiver of the twins.
Correct Answer is D
Explanation
Choice A reason: The “shortcut” scale is not a standard method for the West nomogram, which calculates body surface area (BSA) for precise dosing. Using BSA ensures accuracy for a 76-lb, 50-inch child, making this simplified approach incorrect for calculating a safe pediatric medication dosage in clinical practice.
Choice B reason: Aligning height and weight to a percentage of adult dosage is not how the West nomogram works; it calculates BSA. The correct method uses BSA relative to adult BSA, making this incorrect, as it skips the critical step of surface area calculation for accurate pediatric dosing.
Choice C reason: Multiplying height and weight and dividing the adult dosage is not a nomogram method. The West nomogram uses BSA to adjust doses, comparing child and adult surface areas, making this mathematically incorrect and inappropriate for calculating a safe pediatric medication dose for the child.
Choice D reason: The West nomogram calculates a child’s BSA using height (50 inches) and weight (76 lb), then divides by the average adult BSA (1.7 m²) to find the proportion of the adult dose (300 mg). This method ensures accurate pediatric dosing, making it the correct choice for safe administration.
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