Chapter 19 - Prioritization, Delegation, and Assignment All Verified A+ 2023

Chapter 19 - Prioritization, Delegation, and Assignment All Verified A+ 2023 A 3-month-old infant arrives at the health center for a scheduled well-child visit. The parents ask the nurse why the infant extends the arms and legs in response to a loud sound. Which response by the nurse is *best*? •Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age •Tell the parents that if the behavior does not change by 6 months, the infant will need further evaluation •Remind the parents that this is a normal response that indicates the infant's hearing is intact •Reassure the parents that the behavior is normal and not an indicator of any problem such as cerebral palsy - ANS-•Inform the parents that this is a normal reflex that generally disappears by 4 to 6 months of age •The infant's behavior is consistent with the Moro and startle reflexes. The Moro reflex usually disappears by 6 months of age. The startle reflex usually disappears by 4 months of age. A hearing test is not based on response to loud sounds alone. Although it is true that further evaluation may be needed if the reflexes do not disappear, there is no need for the nurse to discuss this with the parents at this time. The infant's behavior is not consistent with cerebral palsy. Which pediatric pain patient should be assigned to a newly graduated RN? •An adolescent who has sickle cell disease and was recently weaned from morphine delivered via a patient-controlled analgesia device to an oral analgesic; he has been continually asking for an increased dose •A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures •A child who is receiving palliative end-of-life care; the child is receiving opioids around the clock to relieve suffering, but there is a progressive decrease in alertness and responsiveness •A child who has chronic pain and whose medication and nonpharmacologic regimen has recently been changed; the mother is anxious to see if the new regimen is successful - ANS-•A child who needs premedication before reduction of a fracture; the child has been crying and is resistant to any touch to the arm or other procedures •The set of circumstances is least complicated for the child with the fracture, and this would be the best patient for a new and relatively inexperienced nurse. The child is likely to have a good response to pain medication, and with gentle encouragement and pain management, the anxiety will resolve. The other three children have more complex social and psychological issues related to pain management. The nurse caring for a 3-year-old child plans to assess the child's pain using the Wong-Baker FACES® Pain Rating Scale. Which accompanying assessment question would be the *most* useful? •"If number 0 (smiling face) were no pain and number 10 (crying face) were a big pain, what number would your pain be?" •"Can you point to the face picture with one finger and tell me what that pain feels like inside of you?" •"The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" •"If you look at these faces and I give you a paper and pencil, can you draw for me the face that looks most like your pain?" - ANS-•"The smiling face has 'no hurting'; the crying face has a 'really big hurting.' Which face is most like your hurting?" •Pain rating scales using faces (depicting smiling, neutral, frowning, crying, and so on) are appropriate for young children who may have difficulty describing pain or understanding the correlation of pain to numerical or verbal descriptors. The other questions require abstract reasoning abilities to make analogies and the use of advanced vocabulary. The nurse is caring for several children with cancer who are receiving chemotherapy. The nurse is reviewing the morning laboratory results for each of the patients. Which patient condition combined with the indicated laboratory result would cause the nurse the greatest concern? •Nausea and vomiting with a potassium level of 3.3 mEq/L (3.3 mmol/L) •Epistaxis with a platelet count of 100,000/mm3 (100 × 109/L) •Fever with an absolute neutrophil count of 450/mm3 (450 × 109/L) •Fatigue with a hemoglobin level of 8 g/dL (80 g/L) - ANS-•Fever with an absolute neutrophil count of 450/mm3 (450 × 109/L) •National guidelines indicate that rapid treatment of infection in neutropenic patients is essential to prevent complications such as overwhelming sepsis and secondary infections; therefore, the child with fever and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L (3.3 mmol/L) is borderline low and should be monitored. Nosebleeds are common, and the patient and parents should be taught to apply direct pressure to the nose, have the child sit upright, and not disturb the clot. Severe spontaneous hemorrhage is not expected until the platelet count drops below 20,000 mm3 (20 × 109/L). Children can withstand low hemoglobin levels. The nurse should help the patient and parents regulate activity to prevent excessive fatigue. A 7-month-old infant arrives at the health center for a scheduled well-child visit. When the nurse approaches the infant to obtain vital signs, the infant cries vigorously and clings fearfully to the mother. Which of the following phenomena provides the *best* explanation for the infant's behavior? •Separation anxiety •Disassociation disorder •Stranger anxiety •Autism spectrum - ANS-•Stranger anxiety •This infant is displaying stranger anxiety; the child becomes anxious when exposed to unfamiliar people (strangers). Separation anxiety occurs when the child is separated from the primary caregiver; anxiety and crying are also common behaviors. Stranger anxiety and separation anxiety are concurrent and generally begin at 7 to 8 months of age. Disassociation disorder is characterized by disconnected thoughts and is not a disorder of infancy. Autism spectrum is characterized by poor social interaction. The age of the child is significant because autism is not usually detected at 7 months of age. A 6-year-old child who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is the nurse's *best* response to this behavior?...