A 2-year-old client, who has had multiple hospitalizations for ...

[jCorn1234]

A 2-year-old client, who has had multiple hospitalizations for treatment of a congenital disorder, is lying curled in bed holding a stuffed animal and will not interact with the parents. What should the nurse identify as causing this client's behavior?
 
  1. The parents may have been abusing this child.
  2. The child is probably developmentally delayed secondary to multiple hospitalizations.
  3. The child is reacting as a normal 2-year-old.
  4. The child could be suffering from a clinical depression.

Question 2

A newly hospitalized client is demonstrating anxiety and stress. What intervention can the nurse plan to help this client?
 
  1. Explain all procedures in detail before performing them.
  2. Let the client make the majority of decisions about the plan of care.
  3. Control the environment of healing.
  4. Demonstrate staff competence by using multiple nurses for care.

[ciecieme]

Answer to Question 1

Correct Answer: 3
Rationale 1: There is no evidence of parental abuse.
Rationale 2: There is no evidence that the client is developmentally delayed.
Rationale 3: Toddlers and preschool children often react to anxiety by either withdrawing or acting out. This child is behaving in a normal manner.
Rationale 4: There is no evidence that the client is depressed.

Answer to Question 2

Correct Answer: 3
Rationale 1: Explaining all procedures in detail may overwhelm the client. Using short, clear sentences and explaining only enough to satisfy the client is a better plan.
Rationale 2: A client who is ill cannot be expected to make the majority of decisions about the plan of care, but should be allowed as much autonomy and choice as can be arranged and tolerated.
Rationale 3: The nurse is in charge of the environment of healing and should take responsibility for limiting noise, dimming lights at night, using minimal numbers of nurses to care for one client, and keeping the area clean and comfortable.
Rationale 4: Using multiple nurses for care can increase anxiety.