The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?
Obtaining an order to have an indwelling urinary catheter inserted.
Weighing the patient's wet diapers prior to discarding them.
Sitting the patient on the bedpan at least every two hours.
Applying a pediatric urine collection device over the patient's urinary meatus.
The Correct Answer is B
Weighing the patient's wet diapers prior to discarding them.
Choice A rationale:
Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.
Choice B rationale:
Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.
Choice C rationale:
Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.
Choice D rationale:
Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The statement "I feel numb. I just can't believe this is happening”. reflects the emotional reaction of shock. Shock is a common initial response to distressing news, as the individual may find it difficult to process and accept the reality of the situation.
Choice B rationale:
Denial is the refusal to accept reality and is often accompanied by a lack of awareness or acknowledgment of the situation. The mother's statement does not demonstrate denial, as she acknowledges the situation but expresses disbelief.
Choice C rationale:
Anger is a stage of grief characterized by feelings of hostility and resentment. The mother's statement does not show anger, as she does not express any aggressive or hostile emotions.
Choice D rationale:
Depression involves feelings of extreme sadness, hopelessness, and low mood. The mother's statement does not directly convey depression; rather, it indicates a sense of disbelief and numbness.
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
Hypoplastic left heart syndrome involves inadequate development of the left side of the heart, leading to systemic hypoperfusion. It is characterized by decreased pulmonary blood flow due to underdeveloped left heart structures.
Choice B rationale:
Tetralogy of Fallot is characterized by obstruction to blood flow, specifically pulmonary stenosis, which obstructs blood flow from the right ventricle to the pulmonary artery.
Choice C rationale:
Atrial Septal Defect (ASD) is a left-to-right shunt, leading to increased pulmonary blood flow. This occurs because oxygenated blood from the left atrium flows back into the right atrium and then into the pulmonary circulation.
Choice D rationale:
Aortic Stenosis is not correctly matched with its hemodynamic classification. Aortic stenosis involves obstruction to blood flow from the left ventricle to the aorta.
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