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    HESI RN HEALTH ASSESSMENT PROCTORED EXAM

    The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement?

    Explanation & Rationale

    A: Ensure that the room is warm and undress the child completely. While a warm room is important to keep the child comfortable, undressing the child completely can cause distress and discomfort, especially in toddlers who may feel exposed and vulnerable.B: Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary. This approach is more appropriate as it allows the child to remain relatively comfortable and secure. The parent’s involvement helps reassure the child, and only removing necessary clothing minimizes distress. It also allows for targeted examination without fully undressing the child, which is less intimidating for toddlers.C: Help the child take off his/her clothes, removing underwear only to conduct examination of the genitalia. Assisting the child in removing clothes can be helpful, but it might be more comforting and less invasive if the parent is involved in this process. Removing underwear only when necessary for a genital examination is appropriate, but it might still be distressing for the child without prior explanation and parental presence.D: Prior to helping the child remove his/her clothing, use a paper doll to demonstrate removal of clothing. Demonstrating the process using a paper doll can be an effective way to prepare the child for what will happen during the assessment, reducing anxiety. However, this is more of a preparatory step rather than a direct protocol for the physical assessment itself. It can be a helpful adjunct to the primary method but is not sufficient on its own.

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