The nurse would assess respirations in a 9-month-old infant when the client is:
Playing in the playroom.
Crying.
Sleeping.
Laughing.
The Correct Answer is C
Choice A rationale
Playing might cause irregular breathing patterns due to excitement or activity, making it hard to get an accurate respiratory rate.
Choice B rationale
Crying can alter the normal breathing rate and pattern, resulting in an inaccurate assessment of respirations.
Choice C rationale
Sleeping provides the most accurate assessment of respirations, as the infant’s breathing will be at its natural, resting rate.
Choice D rationale
Laughing, similar to crying, causes irregular breathing patterns due to physical exertion and emotions, affecting accuracy.
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Correct Answer is D
Explanation
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
Correct Answer is A
Explanation
Choice A rationale
Giving the toddler a choice between two cups helps to decrease negativism by providing options that still achieve the desired outcome, thereby reducing the likelihood of refusal.
Choice B rationale
Asking the child to take medicine now offers no real choice and is likely to be met with resistance, which is characteristic of negativism in toddlers.
Choice C rationale
This question is too open-ended and can easily be refused, as it does not provide a sense of control or choice for the toddler.
Choice D rationale
Telling the child they "need" to take medicine is directive and authoritarian, which often triggers negativism and a refusal.