eason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their insides
from coming out.
B.) Preschoolers fear physical disability and believe a bandage will prevent
disability.
C.) Preschoolers explore orally and will likely chew or suck on the stitches if l...
1. A preschooler has a small laceration that requires 2 stitches. The nurse covers
the wound with a bandage knowing that it will comfort the child to have it covered.
What is the developmental reason for this intervention?
A.) Preschoolers are magical thinkers and imagine bandages keep their insides
from coming out.
B.) Preschoolers fear physical disability and believe a bandage will prevent
disability.
C.) Preschoolers explore orally and will likely chew or suck on the stitches if left
uncovered.
D.) Preschoolers are concerned with body image and don't want to appear different
than peers. - ANS✓✓A.) Preschoolers are magical thinkers and imagine bandages
keep their insides from coming out.
Rationale: Preschoolers are magical and illogical thinkers and have difficulty
distinguishing fantasy from reality. They have misconceptions about illness, injury,
and bodily functions. For example, they perceive that if their skin is cut, they fear
their insides will leak out. Covering a wound with a bandage helps them with this
fear.
2. 7-month-old presents to the emergency department with a complaint of fever.
Assessment reveals a patent airway and slight cyanosis around his lips and nail
beds. He is alert and interactive. His vital signs are 38.5 C (101.3F), HR 134, RR
32, BP 78/54 mm Hg, and Spo2 84%. The nurse notes a healed surgical scar on his
chest. Based on this assessment, what is the nurse's priority?
A.) Administer ibuprofen to treat the fever.
,B.) Begin oxygen via a nonrebreather mask.
C.) Obtain a surgical history.
D.) Ask if the Spo2 is normal for him. - ANS✓✓D.) Ask if the Spo2 is normal for
him.
Rationale: Children with special healthcare needs may present differently than
other children, but these differences may be normal. The surgical scar on the chest
is likely from a congenital heart defect repair. The mother's chief complaint is the
fever, not the color, pulse oximetry, or the respiratory distress. This may be
because these aspects of his assessment are normal. The intact mental status is also
a sign that he has adapted to lowers oxygen saturation's. The child's baseline must
come from the caregiver before any intervention.
3. An 11-year-old presents to the emergency department with a complaint of
hitting his head while playing soccer. The nurse enters the room and performs an
across-the-room assessment. He is staring at the wall. He has no increased work of
breathing, and his color is pink. Using the pediatric assessment triangle (PAT),
what classification will the nurse assign?
A.) Well
Rationale: In using the PAT, there is not a Well category. A child may appear well
and without disruption in any of the three components of the PAT but is still
designated sick. All pediatric patients presenting to the emergency department are
considered sick simply based on the fact that the caregiver was concerned enough
to bring the child to the emergency department (p. 54).
B.) Sick
Rationale: If there is no disruption in any of the three components of the PAT, a
pediatric patient is considered sick. This child has an abnormality in one of the thre
- ANS✓✓C.) Sicker
Rationale: This child has a disruption in one of the three components of the PAT.
He is staring at the wall, which is a disruption in the general appearance
, component. It may be that he is anxious and fearful about the experience, but it
could be a result of the head injury. More assessment is required (p. 54).
4. The pediatric prioritization process components include the focused assessment,
focused history, acuity rating decision and:
A.) the pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process include the
pediatric assessment triangle (PAT), the focused assessment (objective data), the
focused history (subjective data), and the assignment of the triage acuity rating.
These components ensure enough information is rapidly gathered and used to
provide appropriate care and timely interventions for pediatric patients (p. 52).
B.) developmental characteristics.
Rationale: Developmental characteristics are incorporated into each component of
the pediatric prioritization
process but do not constitute a separate element (p. 52).
C.) head-to-toe assessment.
Rationale: The head-to-toe assessment is part of the focused assessment but not a
separate element (p. 52).
D.) life-savi - ANS✓✓A.) The pediatric assessment triangle (PAT).
Rationale: The four components of the pediatric prioritization process include the
pediatric assessment triangle (PAT), the focused assessment (objective data), the
focused history (subjective data), and the assignment of the triage acuity rating.
These components ensure enough information is rapidly gathered and used to
provide appropriate care and timely interventions for pediatric patients (p. 52).
5. A 2-year-old is brought to the emergency department by her father when he
found her face down in the pool. She remains unresponsive and is breathing
shallowly and slowly. Her color is pale. What is the priority?
A.) Administer 100% oxygen
Rationale: The primary assessment in a trauma patient begins with immobilization
of the cervical spine while opening the airway. The remainder of the primary
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