A 5-year-old boy is brought to the emergency room with a possible broken arm. His 18-year-old sister, who is also his primary caregiver, has come with him. The boy is relatively calm, but his sister is so upset she is nearly hysterical. The nurse notes that as her behaviors show more anxiety, the boy is getting more upset and his anxiety is also increasing. What initial action would be best for the nurse to take in this situation?
While attending to the child, reassure the sister and suggest interventions she can help with.
Ask the sister if she prefers to leave the exam room.
Reassure the child that he is going to be fine and that his sister is just nervous.
Ask his sister to calm down so that she can help her brother remain calm as well.
The Correct Answer is A
Choice A reason: Reassuring the sister while attending to the child and involving her in interventions reduces her anxiety, stabilizing the 5-year-old’s emotional state. This aligns with pediatric emergency care principles, making it the best initial action to manage the escalating anxiety in the emergency room.
Choice B reason: Asking the sister to leave may increase her distress and isolate the child, worsening his anxiety. Reassuring and involving her is more supportive, making this counterproductive and incorrect compared to the nurse’s role in calming both the caregiver and child effectively.
Choice C reason: Reassuring the child about his sister’s nerves doesn’t address her anxiety, which is escalating his distress. Involving the sister in care reduces both anxieties, making this insufficient and incorrect compared to the nurse’s priority of stabilizing the emotional environment in the ER.
Choice D reason: Asking the sister to calm down may heighten her distress, as she’s already hysterical, and doesn’t offer support. Reassuring and involving her helps both, making this ineffective and incorrect compared to the nurse’s action to reduce anxiety for the child and caregiver.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Complying with a babysitter despite being upset shows adaptability, not initiative, which involves self-directed tasks. Attempting to clean cereal reflects proactive behavior, making this less indicative and incorrect compared to an activity demonstrating the 4-year-old’s initiative in the developmental assessment.
Choice B reason: Trying to sweep spilled cereal and crying when failing demonstrates initiative, as the 4-year-old independently attempts a task, a hallmark of Erikson’s initiative stage. This aligns with pediatric developmental milestones, making it the correct activity to document for assessing the child’s growth and development status.
Choice C reason: Refusing to hold hands while crossing the street indicates defiance, not initiative, which involves purposeful self-started activities. Cleaning cereal better reflects initiative, making this incorrect, as it shows autonomy rather than the proactive behavior expected in the initiative stage of development.
Choice D reason: Blaming a broken dish on a fictional friend shows guilt avoidance, not initiative, which involves taking on tasks independently. Attempting a cleanup task is more indicative, making this incorrect compared to the proactive behavior of sweeping cereal in the 4-year-old’s developmental assessment.
Correct Answer is A
Explanation
Choice A reason: Reassuring the sister while attending to the child and involving her in interventions reduces her anxiety, stabilizing the 5-year-old’s emotional state. This aligns with pediatric emergency care principles, making it the best initial action to manage the escalating anxiety in the emergency room.
Choice B reason: Asking the sister to leave may increase her distress and isolate the child, worsening his anxiety. Reassuring and involving her is more supportive, making this counterproductive and incorrect compared to the nurse’s role in calming both the caregiver and child effectively.
Choice C reason: Reassuring the child about his sister’s nerves doesn’t address her anxiety, which is escalating his distress. Involving the sister in care reduces both anxieties, making this insufficient and incorrect compared to the nurse’s priority of stabilizing the emotional environment in the ER.
Choice D reason: Asking the sister to calm down may heighten her distress, as she’s already hysterical, and doesn’t offer support. Reassuring and involving her helps both, making this ineffective and incorrect compared to the nurse’s action to reduce anxiety for the child and caregiver.
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