A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?
Refer the child to social work for early intervention.
Educate the parents on the developmental delays their child is diagnosed with.
Provide the parents with pamphlets for support groups for children with developmental delays.
Discuss the assessment findings with the primary care provider.
The Correct Answer is D
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.
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Correct Answer is B
Explanation
Choice A rationale
Mummy restraints, also known as swaddling, involve wrapping the infant’s body in a blanket to restrict movement. While this method can be used to calm and secure infants during certain procedures, it is not appropriate for postoperative care following cleft lip and palate repair. Mummy restraints do not prevent the infant from touching the surgical site and may cause discomfort.
Choice B rationale
Elbow restraints are the appropriate choice for an infant postoperative following cleft lip and palate repair. These restraints prevent the infant from bending their arms and touching or damaging the surgical site. Elbow restraints allow for some movement and circulation while ensuring the surgical area remains protected during the healing process. They are commonly used in pediatric postoperative care to prevent self-injury.
Choice C rationale
Jacket restraints involve securing the infant’s torso to prevent movement. While jacket restraints can be used in certain situations to ensure safety, they are not suitable for postoperative care following cleft lip and palate repair. Jacket restraints do not specifically prevent the infant from touching the surgical site and may cause unnecessary restriction and discomfort.
Choice D rationale
Wrist restraints involve securing the infant’s wrists to prevent movement. While wrist restraints can be used to prevent self-injury, they are not the best choice for postoperative care following cleft lip and palate repair. Wrist restraints may not effectively prevent the infant from reaching the surgical site and can cause discomfort and distress. .
Correct Answer is A
Explanation
Choice A rationale
Obtaining an influenza vaccine annually is crucial for individuals with type 1 diabetes mellitus. People with diabetes are at a higher risk of complications from infections, including influenza. The flu can lead to elevated blood sugar levels and potentially worsen diabetes control.
Therefore, getting the flu vaccine can help prevent or reduce the severity of the flu and its complications.
Choice B rationale
Administering glucagon is used for severe hypoglycemia, not hyperglycemia. Glucagon is a hormone that raises blood glucose levels by stimulating the liver to release stored glucose. It is typically used in emergency situations when a person with diabetes has very low blood sugar and is unable to consume sugar orally.
Choice C rationale
Insulin should be injected into subcutaneous tissue, not the deltoid muscle. The preferred injection sites for insulin are areas with more subcutaneous fat, such as the abdomen, thighs, buttocks, and upper arms. Injecting insulin into muscle tissue can lead to faster absorption and unpredictable blood glucose levels.
Choice D rationale
Glyburide is an oral medication used to treat type 2 diabetes, not type 1 diabetes. Type 1 diabetes requires insulin therapy because the body does not produce insulin. Glyburide works by stimulating the pancreas to release more insulin, which is not effective for individuals with type 1 diabetes who have little to no insulin production.