the nurse is preparing to examine a 6 year old child which action is most appropriate

NCLEX-RN

NCLEX RN Predictor Exam

1. The nurse is preparing to examine a 6-year-old child. Which action is most appropriate?

A. The child is asked to undress from the waist up.
B. The head is examined before the thorax, abdomen, and genitalia.
C. The nurse should keep in mind that a child at this age will have a sense of modesty.
D. Talking about the equipment being used is avoided to prevent increasing the child's anxiety.

Correct answer: C

Rationale: When examining a 6-year-old child, it is important to consider their sense of modesty. The child should undress themselves, leaving underpants on and using a gown or drape to maintain privacy. Additionally, a school-age child like a 6-year-old is curious about how equipment works, so it is beneficial to explain the purpose and function of the tools being used. The examination sequence should typically progress from the child's head to the toes to ensure a thorough assessment. Therefore, choices A, B, and D are incorrect as they do not align with the appropriate approach to examining a 6-year-old child.

2. During the general survey, what action is a component of the assessment?

A. Observing the patient's body stature and nutritional status
B. Interpreting the subjective information reported by the patient
C. Measuring the patient's temperature, pulse, respirations, and blood pressure
D. Observing specific body systems during the physical assessment

Correct answer: A

Rationale: During the general survey, the nurse assesses the patient's overall appearance, body structure, mobility, and behavior, which includes observing body stature and nutritional status. Interpreting subjective information reported by the patient is part of the subjective data collection process and not the general survey. Measuring vital signs like temperature, pulse, respirations, and blood pressure is part of a focused physical examination, not the general survey. Additionally, observing specific body systems while performing a physical assessment is more specific and focused than the general survey.

3. When teaching a patient to use the three-point gait technique of crutch use:

A. The injured leg moves ahead at the same time as both crutches.
B. One crutch moves at a time and is then followed by the injured leg.
C. Both crutches move ahead at the same time followed by both legs at the same time.
D. None of the above are correct.

Correct answer: A

Rationale: The correct technique for a three-point gait involves the injured leg moving simultaneously with both crutches, followed by the uninjured leg. This gait pattern is utilized when the patient is unable to bear full weight on one of their legs. Choice A accurately describes the appropriate sequence of movements for the three-point gait technique. Choices B and C do not accurately reflect the correct pattern of movement during the three-point gait technique, making them incorrect. Choice D is incorrect as there is a correct option among the choices provided.

4. You are ready to wash your patient's face. You would start by washing what area of the face?

A. The forehead
B. The eyes
C. The ears
D. The cheeks

Correct answer: B

Rationale: When washing a patient's face, it is essential to start by cleaning the eyes. The eye area is considered the priority because moving from an area that can potentially be infected to areas of the face and body that are least able to become infected with a washcloth helps prevent the spread of germs. Washing the forehead, ears, or cheeks before the eyes may risk transferring bacteria to a more sensitive area like the eyes, which could lead to infections or other complications. Therefore, starting with the eyes ensures proper hygiene and reduces the risk of introducing harmful microorganisms to the patient's face.

5. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?

A. Assist the client in using the bathroom one hour after going to bed
B. Give the client a massage before bedtime
C. Tuck bed sheets and blankets tightly around the client once settled in bed
D. Give the client a pair of socks to wear if their feet become cold

Correct answer: D

Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.