What would the nurse consider as an appropriate method to use when completing a physical assessment on a toddler?
Perform traumatic procedures last
Proceed in a head-to-toe direction
Use physical contact immediately
Tell the child to undress themselves
The Correct Answer is A
Rationale:
A. Performing traumatic or invasive procedures (such as examining the ears, mouth, or genital area) last helps build trust and minimizes distress during the assessment.
B. A head-to-toe approach may not be suitable for toddlers due to limited cooperation; flexibility is key.
C. Immediate physical contact can be intimidating and increase anxiety in toddlers—establishing rapport first is important.
D. Most toddlers lack the developmental ability to fully undress themselves; assistance is typically needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Rationale:
Total volume = 250 mL
Time = 2 hr = 120 minutes
Drop factor = 15 gtts/mL
Use the formula:
Flow rate (gtts/min) = (Volume in mL × Drop factor) ÷ Time in minutes
= (250 × 15) ÷ 120
= 3750 ÷ 120
= 31.25 → Round to the nearest whole number = 31 gtts/min
Correct Answer is D
Explanation
Rationale:
A. Keeping the suspicion to oneself can delay necessary intervention and put the child at further risk.
B. Waiting for further evidence is not appropriate; nurses are mandated reporters and do not need to prove abuse—only to report suspicion.
C. Confronting the caregiver may escalate the situation and is not within the nurse’s role for handling suspected maltreatment.
D. Reporting to the appropriate agency (such as child protective services) is the correct and legal action required to protect the child and initiate proper investigation.
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