A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?
Brachial artery
Radial artery
Apex of the heart
Carotid artery
The Correct Answer is A
Rationale:
A. The brachial artery is commonly used to assess the heart rate in infants due to its accessibility and the ease of palpation in smaller limbs.
B. The radial artery is not typically used in infants because it is less accessible and not as easily palpated in this age group.
C. While the apex of the heart is where heart sounds are best auscultated, it is not used to palpate the pulse in infants.
D. The carotid artery is not typically used for assessing the heart rate in infants due to the risk of applying excessive pressure.
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Correct Answer is D
Explanation
Rationale:
A. Constipation is not a typical manifestation of a sickle cell crisis.
B. High fever may occur if an infection is present, but it is not a hallmark symptom of a sickle cell crisis.
C. Bradycardia is not expected during a sickle cell crisis; if anything, tachycardia may be seen due to pain or anemia.
D. Pain is the most common and significant symptom of a sickle cell crisis, caused by the obstruction of blood flow by sickled red blood cells, leading to ischemia and severe pain. This requires immediate attention and pain management.
Correct Answer is C
Explanation
Rationale:
A. While play therapy can be beneficial, it is not the primary focus for a 10-year-old child’s psychosocial needs related to Erikson’s stage.
B. Encouraging visits from friends supports the child's need for social interaction, which is important for psychosocial development during hospitalization.
C. Encouraging the child to complete school work helps maintain a sense of normalcy and supports the child’s need for achievement and competence, which is central to Erikson’s stage of industry vs. inferiority.
D. Consistency is important, and varying the child's schedule may add stress rather than support their psychosocial needs.