A 2-year-old has been admitted to the pediatric unit with a 2-day ...

[iveyjurea]

A 2-year-old has been admitted to the pediatric unit with a 2-day history of vomiting and diarrhea. Which of the following would be a cue the nurse identifies as being outside the normal standard?
 
  1. The child's weight is 25 lb.
  2. The child cries when parents leave the room.
  3. The child is not able to stand alone.
  4. The child is able to hold finger foods.

Question 2

A client has been admitted to the cardiac intensive care unit following an acute myocardial infarction.
 
  The nurse formulates the following nursing diagnosis: Acute pain, related to tissue damage, secondary to infarction, manifested by pallor, client report, and shallow, rapid breathing. Which of the following would be an example of a collaborative intervention?
  1. Provide a calm, quiet atmosphere in the client's room.
  2. Administer pain medication.
  3. Educate the client and family regarding treatment and therapies.
  4. Monitor for changes in the client's condition.

[SeanoH09]

Answer to Question 1

Correct Answer: 3
Rationale: A developmental delay that should cue the nurse to a probable problem would be that this 2-year-old is not able to stand by himself. Most children are walking between 12 months and 18 months. The other data are considered normal behavior for a 2-year-old.

Answer to Question 2

Correct Answer: 2
Rationale 1: This option is not collaborative but rathernurse mediated, which the nurse can implement independently.
Rationale 2: Collaboration occurs between the nurse, physician, and other health care professionals to treat the client's problem. In this case, the physician prescribes medications, and the nurse administers thema primarily dependent action that requires physician orders.
Rationale 3: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.
Rationale 4: This option is not collaborative but rather nurse mediated, which the nurse can implement independently.

[iveyjurea]

Excellent

[CAPTAINAMERICA]

TYSM