The nurse is caring for a hospitalized four-year-old boy. His parents tell the nurse that they will be back to visit at six in the evening. When he asks the nurse when his parents are coming, the nurse's best response would be which of the following?
"They will come around dinner time."
"It won't be much longer."
"They will be here soon."
"Let me show you where 6 o'clock is on the clock."
The Correct Answer is D
A. "They will come around dinner time."
This response uses the term "dinner time," which might be too abstract for a young child. It doesn't provide a specific visual reference.
B. "It won't be much longer."
This response is somewhat vague and may not offer a clear understanding of when the parents will arrive. Young children may not grasp the concept of "much longer."
C. "They will be here soon."
Similar to choice B, this response is somewhat vague and relies on the child's interpretation of "soon," which can vary.
D. "Let me show you where 6 o'clock is on the clock."
This response is the most concrete and provides a visual reference by using the clock. It helps the child understand the passage of time in a more tangible way.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use self/parent report, behavioral, and physiological factors
This choice emphasizes a comprehensive approach to pain assessment, considering self-report if the child can communicate, parent report for younger children or those unable to express themselves verbally, and a combination of behavioral and physiological factors. This approach recognizes the multidimensional nature of pain and aims to gather information from various sources for a more accurate assessment.
B. Ask the parents for a pain rating
While parents' input is valuable, relying solely on parental perception may not capture the full picture of the child's pain experience. It's important to consider other aspects, including the child's self-report (if possible) and behavioral and physiological factors.
C. Look for behavioral clues for pain such as crying
Behavioral observation is a crucial component of pain assessment. However, relying solely on crying may overlook subtle cues or variations in how different children express pain. A more comprehensive approach involves considering various behavioral indicators.
D. Use measures of heart rate and respiratory rate
Physiological measures, such as heart rate and respiratory rate, can provide additional information but should not be used in isolation. Physiological responses can vary, and other dimensions of pain assessment, including self-report and behavioral observations, should be considered for a more complete understanding.
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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