A nurse is preparing to complete an admission assessment on a 2-year-old child. The child is sitting on the parent's lap. Which technique should the nurse implement to complete the physical exam?

Correct Answer: C

Rationale: The most appropriate technique in this scenario would be to perform the exam while the child is on the parent's lap. This approach helps build trust and comfort for the child, as they are in a familiar and secure environment. It can also help the nurse assess the child's behavior and interactions with the parent during the exam, providing valuable information about the child's developmental stage and emotional well-being. Additionally, conducting the exam in this way can help reduce anxiety and fear that the child may experience in an unfamiliar setting like the hospital crib or exam room.

Correct Answer: D

Rationale: Asking the child to draw a picture can be the most helpful technique in this situation because it allows the child to express themselves visually, especially when verbal communication may be challenging. Drawing can serve as a form of communication that the child may find more comfortable and engaging. It provides the child with a non-verbal way to express their thoughts, feelings, and experiences, which can help the nurse better understand the child's perspective and potentially build a connection with them. Additionally, examining the child's drawings can provide valuable insights into their emotional state and concerns, facilitating more effective care and support.

Correct Answer: B

Rationale: The nurse should instruct the client to rotate injection sites within the same anatomic region, not among different regions. Proper rotation of injection sites helps prevent lipodystrophy (changes in fat tissue) and ensures consistent absorption of insulin. By rotating sites within the same region, the client can minimize the risk of developing localized skin complications. Additionally, rotating sites helps to ensure that the insulin is absorbed consistently, leading to more predictable blood glucose control. It is important to avoid injecting into areas of scar tissue, hypotrophy, large blood vessels, or nerves, as these can affect the absorption of insulin and may lead to inconsistent blood glucose levels.

Correct Answer: A

Rationale: Right-sided heart failure is characterized by the inability of the right side of the heart to pump blood effectively, leading to fluid accumulation in the systemic venous system. This fluid overload typically manifests as signs of congestion in the peripheral tissues. Dependent pitting edema is a classic symptom of right-sided heart failure, where swelling is noted in the lower extremities and sacral area, worsening later in the day due to the effects of gravity. Orthopnea (B) and exertional dyspnea (C) are more indicative of left-sided heart failure, where congestion occurs in the pulmonary system. Hemoptysis (D) refers to coughing up blood and is not a classic symptom of heart failure but may be seen in conditions such as pulmonary embolism or infection.

Correct Answer: B

Rationale: Keeping the extremities at a neutral position for a client with a neurologic disorder can help reduce hemostasis and decrease the potential for thrombophlebitis. This positioning helps maintain proper blood flow and prevents excessive pressure on the veins, which can lead to blood clots. Removing and reapplying elastic stockings, changing the client's position, and using a flotation mattress may have their own benefits, but in this case, keeping the extremities at a neutral position is the most direct and effective intervention to address the issue of hemostasis and thrombophlebitis for a client with a neurologic disorder.