While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?

Correct Answer: B

Rationale: Separation anxiety peaks at this age, significantly impacting behavior.

Correct Answer: C

Rationale: Patting the area dry after cleaning during perineal care prevents moisture-related irritation and skin breakdown, common in incontinent patients. Harsh soaps can strip natural oils, causing dryness or infection, so mild cleansers are better. Wiping back to front risks introducing fecal bacteria to the urethra, increasing UTI chances, especially in females front-to-back is the standard. Limiting care to once a week neglects hygiene needs, as incontinence requires frequent cleaning to avoid rashes or infections. Gentle drying maintains skin integrity, reducing friction and promoting comfort, which is critical for patients unable to manage their own hygiene.

Correct Answer: B

Rationale: Lukewarm water is ideal for bathing as it cleans effectively without risking burns or chilling the patient, especially those with reduced sensation or circulation, like the elderly. Extremely hot water can scald, causing injury, while ice-cold water may shock the system or cause discomfort, particularly in frail patients. Patient preference matters, but safety trumps comfort nurses must ensure the temperature is within a safe range (typically 38-40°C). Lukewarm water balances hygiene, comfort, and protection, preventing skin damage and maintaining dignity during this intimate task, a key aspect of basic care.

Correct Answer: D

Rationale: Passive range-of-motion exercises, where the nurse moves the patient's limbs, maintain joint mobility and prevent contractures in bedridden patients unable to move themselves. This preserves flexibility and circulation, staving off stiffness and deformity from disuse. Independence isn't the immediate goal assistance is required. Assessing strength might occur incidentally, but it's not the purpose; active exercises test that. Exercise for staff is a byproduct, not the intent it's patient-focused. Nurses perform this to counteract immobility's effects, ensuring long-term joint health and comfort in dependent care scenarios.

Correct Answer: C

Rationale: A cooling blanket reduces a febrile patient's body temperature by transferring heat away from the skin, countering fever's effects and preventing complications like seizures. Inducing shivering raises temperature opposite of the goal and wastes energy. Providing warmth worsens fever, delaying recovery. Sweating might occur but isn't the aim; toxin elimination is a misconception cooling targets thermoregulation. Nurses use this to safely lower fever, monitoring closely to avoid overcooling, ensuring comfort and stability in hyperthermic states.