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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "This is common for teens to threaten suicide when they want attention."
This statement is dismissive and could contribute to a lack of appropriate intervention. It is essential not to trivialize or assume that all suicide threats are attention-seeking, as they may indicate underlying distress and a need for support.
B. "Your friend's threat needs to be taken seriously and immediate help for your friend is important."
This is the most appropriate response. It acknowledges the seriousness of the situation, emphasizes the need for immediate help, and reflects a responsible and caring approach to addressing a friend's mention of suicide.
C. "If your friend mentions suicide a second time, you will want to get your friend some help."
Waiting for a second mention is not appropriate, as any mention of suicide should be treated seriously. Delaying intervention until a second mention could be dangerous, as the friend may be in immediate distress.
D. "You need to gather details about your friend's suicide plan."
While gathering information about a friend's thoughts and plans is important for a comprehensive assessment, it is not the primary concern in the immediate response to a suicide mention. The immediate focus should be on ensuring the friend's safety and involving appropriate professionals for help.
Correct Answer is B
Explanation
A. An abnormal finding-indicates the need for developmental assessment.
This is not accurate. The closure of the anterior fontanel within the expected age range does not indicate an abnormal finding or the need for additional developmental assessment.
B. A normal finding.
This is the correct interpretation. The anterior fontanel normally closes between 12 to 18 months, and closure by 19 months is within the expected developmental range.
C. An abnormal finding-indicates the need for immediate referral to a practitioner.
This is not necessary based on the information provided. The closure of the anterior fontanel within the expected timeframe is a normal finding.
D. A questionable finding-the infant should be rechecked in 1 month.
There's no need for rechecking in 1 month. The closure of the anterior fontanel at 19 months is considered normal.
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