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DETAILED ANSWERS WITH RATIONALES (VERIFIED
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Question
A nurse in a pediatric unit is preparing to insert an IV catheter for a 7-year-old
child. Which of the following actions should the nurse take?
A. (Unable to read)
B. Tell the child they will feel discomfort during the catheter insertion.
C. Use a mummy restraint to hold the child during the catheter insertion.
D. Require the parents to leave the room during the procedure
✔️ Correct Answer: B. Tell the child they will feel discomfort during the
catheter insertion.
Expert Rationale:
A 7-year-old child is in the school-age developmental stage, where cognitive
abilities allow for logical thinking and an improved understanding of cause-and-
,effect relationships. Nursing care should focus on honesty, preparation, and
promoting cooperation through therapeutic communication.
Option B (Correct):
Providing truthful, age-appropriate information such as “you will feel some
discomfort” helps reduce anxiety and builds trust. School-age children cope
better when they are prepared for sensations they will experience rather than
being misled or given vague explanations.
Option C (Incorrect):
A mummy restraint is appropriate for infants or very young children who
cannot cooperate. Using it on a school-age child is developmentally
inappropriate and can increase fear, loss of control, and trauma.
Option D (Incorrect):
Parents should generally be allowed to remain with the child during
procedures. Their presence provides emotional security, reduces anxiety, and
improves cooperation.
Option A (Incomplete):
Not assessable, but does not reflect correct pediatric communication
principles.
NCLEX Focus:
Pediatric procedural preparation and therapeutic communication
DIF:
Application
REF:
,Pediatric Nursing / Developmental Stages
OBJ:
Apply appropriate communication strategies for school-age children during
procedures
TOP:
Psychosocial Integrity / Growth and Development
2. A nurse is caring for a client who has arteriovenous fistula Which of the
following findings should the nurse report? A. Thrill upon palpation.
B. Absence of a bruit.
C. Distended blood vessels
D. Swishing sound upon auscultation
✔️ Correct Answer: B. Tell the child they will feel discomfort during the catheter
insertion.
Expert Rationale:
At 7 years of age, the child is in the school-age developmental stage. Children in this
stage have improved cognitive understanding and value honesty and clear
explanations. They are able to understand cause-and-effect relationships and respond
better when procedures are explained in simple, truthful terms.
Option B (Correct):
Providing honest, age-appropriate information such as “you will feel some
discomfort” helps build trust, reduces fear of the unknown, and promotes
cooperation. School-age children respond best when they are prepared for what they
will feel rather than being misled or given false reassurance.
Option C (Incorrect):
A mummy restraint is typically used for infants or very young children who cannot
, cooperate or understand instructions. Using such a restraint on a 7-year-old would be
developmentally inappropriate, increase anxiety, and potentially cause psychological
distress or resistance.
Option D (Incorrect):
Parents should generally be allowed to stay with the child during procedures
whenever possible. Their presence provides emotional support, reduces anxiety, and
improves the child’s sense of security.
Option A (Incomplete):
This option is not readable; however, based on NCLEX standards, any incorrect or
irrelevant instruction would not align with therapeutic communication principles for
school-age children.
NCLEX Focus:
Pediatric developmental stage communication and procedural preparation
DIF:
Application
REF:
Pediatric Nursing / Developmental Considerations / School-Age Child
OBJ:
Apply appropriate communication techniques for school-age children undergoing
procedures
TOP:
Safety and Infection Control / Nursing Process: Implementation
3. A nurse is providing discharge teaching for a client who has an