Answer to Question 1
2
Rationale:
1. The major source of stress for hospitalized school-age children is concern with death and dying.
2. The adolescent desires privacy and independence.
3. Preschoolers are fearful of loss of self-control related to the body and emotions, and fear of bodily injury or mutilation.
4. Separation from parents is the major stressor for the toddlers.
Answer to Question 2
2
Rationale 1: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
Rationale 2: The nurse checks the extremity to determine adequacy of circulation following a cardiac catheterization. An extremity that is warm with capillary refill of less than three seconds has adequate circulation. Other indicators of adequate circulation include palpable pedal (dorsalis and posterior tibial) pulses, adequate sensation, and pinkness of skin color.
Rationale 3: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
Rationale 4: If the capillary refill is over three seconds; if any of the pedal pulses are absent and/or weakened; or if the extremity is cool, cyanotic, or lacking sensation, circulation might not be adequate.
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