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The nurse needs to take a B/P on a 3 year old who is in the playroom. What is the best intervention?

Document B/P not obtained because child was in the playroom.

Take the child back to their room, take their B/P and then take them back to the playroom.

Take the child to the treatment room.

Take the B/P in the playroom.

Answer and Explanation

The Correct Answer is D

A. Document B/P not obtained because the child was in the playroom.

This is not the best option. The nurse should attempt to obtain the blood pressure as part of routine monitoring.

B. Take the child back to their room, take their B/P and then take them back to the playroom.

This may disrupt the child's play and is not the most efficient approach for routine blood pressure monitoring.

C. Take the child to the treatment room.

This might be unnecessary for a routine blood pressure check and could cause unnecessary anxiety for the child.

D. Take the B/P in the playroom.

This is the best intervention. If possible, taking the blood pressure in the playroom allows the child to remain in a familiar and comfortable environment, reducing anxiety and promoting cooperation.

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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.

A. Serum calcium B. Urine creatinine C. Sweat chloride test D. Bronchoscopy

Correct Answer is C

Explanation

A. Serum calcium:

- Serum calcium levels are not typically used to diagnose cystic fibrosis. Calcium levels are more related to bone health, neuromuscular function, and various metabolic processes. While electrolyte imbalances can occur in CF, serum calcium alone is not specific for its diagnosis.

B. Urine creatinine:

- Urine creatinine is not a diagnostic test for cystic fibrosis. Creatinine is a waste product produced by muscles and excreted by the kidneys. Monitoring creatinine levels is more related to assessing kidney function and is not specific to CF diagnosis.

C. Sweat chloride test:

- The sweat chloride test is considered the gold standard for diagnosing cystic fibrosis. Individuals with CF have higher than normal levels of chloride in their sweat. This test measures the amount of chloride in the sweat, and a high level is indicative of CF. It is a noninvasive and reliable diagnostic test for CF.

D. Bronchoscopy:

- Bronchoscopy is not used as a primary diagnostic test for cystic fibrosis. While it may be performed for other reasons, such as assessing airway abnormalities or obtaining samples for culture, it is not the primary method for diagnosing CF.

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The nurse needs to take a B/P on a 3 year old who is in the playroom. What is the best intervention?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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