An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is which?

Correct Answer: C

Rationale: The most appropriate nursing action in this scenario is to choose option C, which is to explain in simple terms how the blood pressure apparatus works to the 8-year-old girl. This option is the best choice because it promotes open communication, provides education in a developmentally appropriate way, and empowers the child by addressing her curiosity and need for information. Explaining in simple terms how the blood pressure apparatus works helps the child understand the procedure and reduces anxiety by demystifying the medical equipment. It fosters trust between the nurse and the child, which is crucial in pediatric nursing care. By addressing the child's question directly, the nurse acknowledges her autonomy and respects her right to information about her own healthcare. Option A, asking the girl why she wants to know, and option B, determining why she is anxious, are not the best choices in this situation. These options do not directly address the child's query or provide her with the information she is seeking about the blood pressure apparatus. Option D, telling her she will see how it works as it is used, dismisses her curiosity and misses an opportunity for patient education and engagement. In pediatric nursing care, it is essential to engage with children in a developmentally appropriate and informative manner to build trust, reduce anxiety, and promote their understanding of their healthcare experiences. By choosing option C, the nurse can support the child's curiosity, provide education, and enhance the overall quality of care provided.

Correct Answer: A

Rationale: In the context of nursing care of children, gathering a comprehensive health history is crucial in order to provide holistic care. The correct answer, A) Review of systems, is essential because it allows the nurse to assess the child's overall health status, identify any underlying issues, and understand the child's past medical history, current symptoms, and any potential risk factors. This information helps in formulating an appropriate care plan and identifying any potential problems that may affect the child's health. Option B) Physical assessment is also important in pediatric nursing care, but it focuses more on the current physical condition of the child rather than past medical history or potential risk factors. While growth measurements (C) and vital signs (D) are important components of a pediatric assessment, they are more focused on the current physical status of the child rather than obtaining a comprehensive health history. Educationally, understanding the significance of conducting a thorough health history in pediatric nursing is crucial for students to develop critical thinking skills, clinical reasoning abilities, and the ability to provide safe and effective care to pediatric patients. By emphasizing the importance of gathering a detailed health history, students can learn to approach patient care in a systematic and comprehensive manner, ensuring that all aspects of the child's health are considered in their care plan.

Correct Answer: B

Rationale: In the context of nursing care of children, determining the chief complaint when taking a health history of an adolescent is crucial for providing effective care. Option B, "Ask the adolescent, 'Why did you come here today?'" is the correct choice because it directly involves the adolescent in expressing their reason for seeking healthcare, empowering them to be active participants in their own care. This approach promotes patient-centered care and encourages open communication between the nurse and the adolescent. Option A, requesting a detailed listing of symptoms, may be overwhelming for the adolescent and may not capture the primary reason for their visit. It is important to remember that adolescents may not always be able to articulate their symptoms clearly, making it essential to approach them in a supportive and non-threatening manner. Option C, interviewing the parent away from the adolescent, is not ideal as it bypasses the adolescent's perspective and may lead to missing important information or concerns that the adolescent themselves may have. Option D, using what the adolescent says to determine the problem in medical terminology, may not be appropriate as it can create a barrier to effective communication and understanding between the nurse and the adolescent, potentially leading to misinterpretation of the chief complaint. In an educational context, it is important to teach nursing students the significance of involving adolescents in their care, respecting their autonomy, and promoting open communication to ensure holistic and patient-centered care delivery. Building trust and rapport with adolescent patients is essential in providing quality care in the nursing practice.

Correct Answer: A

Rationale: In this scenario, the correct heading to record the information provided by the mother is under "History." This is because the information about a difficult delivery and premature birth is considered past medical history which is typically documented under the history section of a patient's medical record. Option B, "Present illness," would be incorrect as this heading is typically used to document the current health concerns or issues the patient is experiencing at the time of the visit. The information provided by the mother pertains to events that occurred in the past. Option C, "Chief complaint," would also be incorrect as this heading is used to document the main reason for the patient seeking medical attention during the current visit. The information provided does not represent a current complaint. Option D, "Review of systems," would be incorrect as this heading is typically used to document a systematic review of the patient's body systems to identify any current or potential health issues. The information provided does not relate to the review of current symptoms. Educationally, it is important for nurses to accurately document patient history as it provides crucial information for understanding the patient's overall health status, planning appropriate care, and making informed clinical decisions. Understanding the correct organization of a patient's medical record is essential for effective communication among healthcare providers and ensuring continuity of care.

Correct Answer: A

Rationale: In the health history, a record of immunizations belongs under the "History" section. This is because immunizations are a crucial aspect of a patient's medical history, providing important information about the individual's past and current vaccination status. Including immunizations in the history section allows healthcare providers to easily track and verify the vaccinations a child has received, ensuring they are up to date with recommended vaccines and protected against preventable diseases. Option B, "Present illness," is incorrect because immunizations are not directly related to the current illness or chief complaint. Option C, "Review of systems," is also incorrect as this section focuses on specific symptoms and not on past medical interventions like immunizations. Option D, "Physical assessment," is not the appropriate section for documenting immunizations as it pertains to the physical examination findings of the patient, not their medical history. Educationally, understanding where to document immunizations in a health history is essential for nurses caring for children. It ensures accurate and comprehensive documentation, aiding in providing safe and effective care. By placing immunizations in the history section, nurses can easily access this vital information when making clinical decisions, promoting optimal health outcomes for pediatric patients.