The nurse is assessing a four-year-old child with a possible ...

[craiczarry]

The nurse is assessing a four-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Standard Text: Select all that apply.
 
  1. Fails to make eye contact
  2. Flinches when touched on the arm
  3. History of limited prenatal care and precipitant delivery
  4. Head circumference has not changed in over one year
  5. Flat facial expressions

Question 2

The nurse administers the flu vaccine to a school age child. After administering the vaccine, the nurse will document: Standard Text: Select all that apply.
 
  1. The date of the last flu vaccine.
  2. The site of the vaccination.
  3. The lot and serial number of the vaccine.
  4. The date and time of administration.
  5. Who assisted in restraining the child.

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Answer to Question 1

1,2,3,5
Rationale 1: Making eye contact with the nurse and caregiver is part of the child's overall affect and social skills. A child who fails to make eye contact may have an alteration in mental health.
Rationale 2: Flinching may indicate a desire to avoid contact; this can indicate a mental health issue and should be further evaluated.
Rationale 3: History of prenatal care and delivery can help determine potential alterations in mental health in a child.
Rationale 4: Head circumference is not measured in a four-year-old.
Rationale 5: Affect can be determined by facial expression and response to the nurse, helping to determine mental health.
Global

Answer to Question 2

2,3,4
Rationale 1: This information is not pertinent.
Rationale 2: The site should be recorded.
Rationale 3: This information should be recorded in case a problem develops.
Rationale 4: This should be recorded.
Rationale 5: This information is not pertinent.
Global Rationale:

[craiczarry]

TYSM

[nanny]

Thanks for the timely response, appreciate it