A mother brings her male preschooler to the clinic because he has had diarrhea, vomiting, and high fevers for the past three days.
The child begins to cry and cling to his mother when the nurse enters the examination room.
Which action should the nurse implement to get the child to cooperate?
Request extra staff to help with the nursing assessments.
Explain to the child the reasons an examination is needed.
Talk to the mother and gradually focus on the child's toy.
Complete the assessment while allowing the child to cry.
The Correct Answer is C
Choice A rationale
Requesting extra staff to help with the nursing assessments may not be the most effective approach. It could increase the child's anxiety due to the presence of more unfamiliar people in the room. The primary goal is to create a calm environment that helps the child feel safe and more cooperative.
Choice B rationale
Explaining the reasons for the examination to the child may not be effective for a preschooler who may not fully understand or be comforted by such explanations. Young children often require more tangible and immediate means of reassurance and distraction.
Choice C rationale
Talking to the mother and gradually focusing on the child's toy is a practical approach. This strategy helps build rapport with both the mother and the child, and using the toy as a focal point can distract and comfort the child, making the examination process less intimidating and more cooperative.
Choice D rationale
Completing the assessment while allowing the child to cry may not be ideal. It can increase the child's distress and make the assessment more challenging. Addressing the child's emotional needs by providing comfort and distraction can lead to a more successful and less stressful examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Correct Answer is A
Explanation
Choice A rationale
Placing the client in Trendelenburg position is the first action as it helps to relieve pressure off the umbilical cord by using gravity to shift the fetus away from the pelvis. This position helps to prevent cord compression and maintain blood flow to the fetus.
Choice B rationale
Notifying the operating room team is important but should be done after immediately addressing the umbilical cord prolapse to prevent fetal hypoxia. Initial physical intervention takes priority.
Choice C rationale
Administering oxygen via face mask is beneficial for the mother and fetus but is not the immediate first action. Positioning the client to relieve pressure off the umbilical cord is more urgent.
Choice D rationale
Administering a fluid bolus of 500 mL can help maintain maternal blood pressure, but it is not the first action. The priority is to reposition the client to prevent cord compression.
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