The nurse is preparing to give an injection to a 3-year-old child. Which of the actions by the nurse is appropriate? (Select all that apply)

Allow the child to wait until later that afternoon after a trip to the playroom to receive the injection.

Provide comfort measures after the procedure, such as touching, holding, or providing a favorite toy.

Accept aggressive behavior, within reasonable limits, as a normal response, and provide healthy outlets for the child.

Offer a brief, concrete explanation of the procedure and then perform it.

Answer and Explanation

Correct Answer : B,C,D

A. Delaying the injection may increase the child's anxiety and fear regarding the procedure; it is better to proceed without unnecessary delays.

B. Providing comfort measures after the injection helps to ease the child's distress and provides reassurance during recovery.

C. Accepting and acknowledging the child’s aggressive behavior as a normal reaction to fear helps the child process their feelings, while offering healthy outlets helps manage these feelings.

D. Offering a brief, concrete explanation helps prepare the child for what to expect, reducing anxiety and making the procedure more manageable.

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Correct Answer is A

Explanation

A. A facial grimace is a common indicator of pain in infants and suggests discomfort, prompting further assessment.

B. Dry palms and feet are not specific indicators of pain and can be influenced by other factors such as dehydration or environmental conditions.

C. Wide-open eyes in an infant can occur for various reasons, including curiosity or surprise, and are not specifically indicative of pain.

D. Decreased muscle tone can indicate various conditions, but it is not a direct sign of pain and may require further evaluation.

A. Look for signs such as staying dry for at least 2 hours during the day or waking up dry from naps. B. Encourage the child to sit on the potty chair for a few minutes several times a day, even if they do not use it. C. Discipline the child when they wet themselves D. Wait until the child shows interest in using the toilet and can follow simple instructions. E. Start potty training as soon as the child turns 18 months old.

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

Explanation

A. Staying dry for extended periods and waking up dry are clear indicators that the child may be ready for potty training.

B. Encouraging the child to sit on the potty, even without using it, helps familiarize them with the process, which is beneficial for readiness.

C. Discipline for accidents can create anxiety and resistance toward potty training; it is important to approach the process positively.

D. Waiting for signs of interest and the ability to follow simple instructions respects the child's developmental readiness, making the transition smoother.

E. Starting potty training too early can lead to frustration for both the child and parents; readiness should be based on the child’s cues rather than age alone.

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The nurse is preparing to give an injection to a 3-year-old child. Which of the actions by the nurse is appropriate? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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The nurse is preparing to give an injection to a 3-year-old child. Which of the actions by the nurse is appropriate? (Select all that apply)