A nurse is attempting to obtain information from a child who is hearing impaired. Which of the following actions should the nurse take?
Speak slowly while facing the child.
Talk directly into the child's impaired ear.
Stand above the child's eye level when speaking.
Speak loudly to the child.
The Correct Answer is A
A. Speak slowly while facing the child: Facing the child helps them see lip movements and facial expressions, which aids communication.
B. Talk directly into the child's impaired ear: Shouting or talking directly into the ear is unhelpful and can distort sound further.
C. Stand above the child's eye level when speaking: Standing above the child can make communication difficult. The nurse should be at eye level to establish effective communication.
D. Speak loudly to the child: Speaking loudly can distort sound and is not helpful for a hearing-impaired child.
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Correct Answer is C
Explanation
A. Insomnia: Infants with increased ICP are more likely to be lethargic than to have insomnia.
B. Positive Babinski reflex: A positive Babinski reflex is normal in infants under 2 years and does not indicate ICP.
C. Bulging fontanel: A bulging fontanel is a classic sign of increased ICP due to the accumulation of fluid or swelling inside the skull.
D. Low-pitched cry: Infants with ICP typically have a high-pitched cry, not a low-pitched one.
Correct Answer is A
Explanation
A. "Give her acetaminophen, not aspirin.": Aspirin is contraindicated in children due to the risk of Reye's syndrome, a rare but serious condition that affects the liver and brain, especially during viral illnesses like the flu or chickenpox. Acetaminophen is a safer alternative for fever management in children.
B. "You'll have to call your physician.": While seeking physician advice is important, the nurse has a duty to provide accurate, immediate, evidence-based guidance to prevent harm.
C. "Give her no more than three baby aspirin every 4 hours.": Recommending aspirin dosing is unsafe due to the risk of Reye's syndrome.
D. "Follow the directions on the aspirin bottle for her age and weight.": Providing this advice without addressing safety concerns is inappropriate and potentially harmful.