The nurse is trying to complete a physical exam for a hospitalized 18-month-old with respiratory syncytial virus (RSV). The child is in the crib kicking, screaming, and trying to grip her mother, making the exam very difficult. The mother is visibly upset and asks, “Is there any other way we can do this?” The best response from the nurse is:
You can stand next to the crib during the exam and hold her arms down so I can listen to her lungs
You can pick her up and soothe her. Let’s try the exam while you hold her in your lap
I will let her calm down and come back when I am done with all my other patient exams and morning meds
I need to get this exam done and listen to her lungs. Unfortunately, this is the only way
The Correct Answer is B
Choice A reason: Holding the child’s arms down while in the crib may increase distress and resistance in an 18-month-old with RSV, who is already agitated. This approach disregards developmental needs for comfort, potentially worsening anxiety and making the exam more difficult, rendering it an ineffective strategy.
Choice B reason: Holding the 18-month-old on the mother’s lap provides comfort, reducing anxiety and resistance during the exam. This developmentally appropriate approach leverages the child’s trust in the caregiver, facilitating cooperation and effective assessment of respiratory status in RSV, making it the best response.
Choice C reason: Delaying the exam until later risks missing critical changes in the child’s respiratory status, as RSV can cause rapid deterioration in young children. Immediate assessment is necessary, and postponing does not address the mother’s distress or the child’s needs, making this an inappropriate response.
Choice D reason: Stating that restraining in the crib is the only way ignores developmental considerations for an 18-month-old. Comforting the child on the mother’s lap is a viable alternative that reduces distress and facilitates the exam, making this an incorrect and inflexible response to the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Bubble baths can irritate the urethra and introduce bacteria, increasing the risk of urinary tract infections in children with vesicoureteral reflux, where urine flows backward from the bladder to the ureters. This practice is contraindicated, making it an incorrect inclusion in the teaching plan for parents.
Choice B reason: Holding urine for 6 to 8 hours promotes urinary stasis, increasing the risk of bacterial growth and infections in vesicoureteral reflux. Frequent voiding is recommended to flush the urinary tract, making this instruction harmful and incorrect for managing the condition effectively in children.
Choice C reason: Prophylactic antibiotics are often prescribed in vesicoureteral reflux to prevent recurrent urinary tract infections, which can lead to kidney damage. By reducing bacterial colonization in the urinary tract, antibiotics protect renal function, making this a critical component of the teaching plan for parents to ensure compliance.
Choice D reason: Fluid restrictions are not indicated for vesicoureteral reflux. Increased fluid intake promotes frequent urination, flushing bacteria from the urinary tract and reducing infection risk. Restricting fluids could exacerbate the condition, making this an incorrect and harmful suggestion for the teaching plan.
Correct Answer is ["88"]
Explanation
Step 1: Calculate the total fluid volume for 24 hours.
4 mL × 16 kg × 22 = 1408 mL
Result at step 1 = 1408 mL
Step 2: Determine the fluid volume for the first 8 hours.
Half of the total volume is given over the first 8 hours.
1408 mL ÷ 2 = 704 mL
Result at step 2 = 704 mL
Step 3: Calculate the hourly rate for the first 8 hours.
704 mL ÷ 8 hours = 88 mL per hour
Final answer 88 mL per hour
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