The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement?

Ensure that the room is warm and undress the child completely.

Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary.

Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia.

Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing.

Answer and Explanation

The Correct Answer is B

A: Ensure that the room is warm and undress the child completely. While a warm room is important to keep the child comfortable, undressing the child completely can cause distress and discomfort, especially in toddlers who may feel exposed and vulnerable.

B: Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. This approach is more appropriate as it allows the child to remain relatively comfortable and secure. The parent’s involvement helps reassure the child, and only removing necessary clothing minimizes distress. It also allows for targeted examination without fully undressing the child, which is less intimidating for toddlers.

C: Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. Assisting the child in removing clothes can be helpful, but it might be more comforting and less invasive if the parent is involved in this process. Removing underwear only when necessary for a genital examination is appropriate, but it might still be distressing for the child without prior explanation and parental presence.

D: Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing. Demonstrating the process using a paper doll can be an effective way to prepare the child for what will happen during the assessment, reducing anxiety. However, this is more of a preparatory step rather than a direct protocol for the physical assessment itself. It can be a helpful adjunct to the primary method but is not sufficient on its own.

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Correct Answer is C

Explanation

A. Assess daily alcohol intake: Alcohol misuse can contribute to a variety of psychiatric symptoms, including hallucinations or delusions. Older adults may metabolize alcohol differently, leading to higher susceptibility to its effects. While this is important, it may not be the first priority unless there are clear signs of alcohol misuse (e.g., smell of alcohol, history provided by the client or family).

B. Identify signs of depression: Depression in older adults can sometimes present with psychotic features, including hallucinations or delusions. Understanding the client's emotional state and identifying symptoms of depression can provide insight into the cause of their behaviour. Depression is common in older adults and can be a precursor or a component of other psychiatric conditions.

C. Determine cognitive status: Cognitive impairment (e.g., dementia) can often present with hallucinations or delusions, and evaluating cognitive status can help differentiate between different types of disorders (e.g., dementia vs. primary psychotic disorders). Assessing cognitive function helps in identifying conditions like Alzheimer's disease or other dementias where hallucinations can be a symptom. This assessment can guide the further direction of evaluation and treatment, making it a critical first step.

D. Review risk factors for abuse: Older adults are at risk of abuse, which can include physical, emotional, and financial abuse. Identifying these risk factors is crucial for their safety and well-being. While this is a significant concern, unless there are immediate signs or disclosures of abuse, it may not be the most urgent assessment in the context of hallucinations.

A. Conduct an assessment of functional capacity and environmental hazards. B. Distinguish between symptoms caused by disease and those due to aging. C. Obtain a medication history including prescription and non-prescription drugs. D. Emphasize the need to place advance directives in the medical record.

Correct Answer is C

Explanation

A. Functional capacity: While important for older adults, it's not the most pressing concern during this routine follow-up exam.

B. Distinguishing symptoms: This is an ongoing process, but not the most critical element for this visit.

C. Obtain a medication history including prescription and non-prescription drugs. Cataract surgery often involves medication changes or new medications to prevent infection or manage other post-operative needs. An updated medication history helps identify potential interactions or side effects.

D. Advance directives: While important for all adults, it might not be the most urgent topic for this specific follow-up exam focused on managing existing conditions and potential post-surgical medications.

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The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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