A nurse is caring for a preschooler who is the hospital for sickle cell disease. Which of the following should the nurse identify as an expected behavior of a preschool-age-child?
Describing manifestations of the illness.
Relating fears to magical thinking
Awareness of body function.
Understanding cause of illness
The Correct Answer is B
A. Describing manifestations of the illness: Preschoolers lack the cognitive ability to describe symptoms in detail.
B. Relating fears to magical thinking: Magical thinking is characteristic of preschoolers, and they may associate illness with punishment or fantastical causes.
C. Awareness of body function: This is more typical of school-age children, not preschoolers.
D. Understanding cause of illness: Preschoolers do not have the cognitive development to understand illness causation fully.
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Correct Answer is B
Explanation
A. Restrain the toddler for 1 hr after the procedure: Restraint is not appropriate post-procedure. The child should be monitored for complications but not physically restrained unless medically necessary.
B. Place the toddler in a side-lying, knee-chest position: This position flexes the spine and opens the spaces between the vertebrae, allowing for easier access to the subarachnoid space for the lumbar puncture.
C. Ask another nurse to assist with holding the toddler in a prone position: The prone position is incorrect for lumbar punctures. The side-lying, knee-chest position is standard.
D. Swaddle the toddler in a warm blanket: Swaddling may comfort the toddler but does not facilitate the lumbar puncture.
Correct Answer is A
Explanation
A. Aura: An aura is a subjective sensation experienced before a seizure, such as a strange smell, taste, or visual change. It can provide clues about the seizure's origin in the brain, often linked to the temporal lobe.
B. Blood Pressure 90/60: Blood pressure is an objective, measurable sign, not subjective data reported by the child.
C. Oxygenation on room air 97%: Oxygenation levels are objective and do not provide information about seizure origin.
D. Temperature 38 degrees Celsius: Temperature is objective and does not help localize the seizure's origin in the brain.