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 ["B","C","E"]
Explanation
Choice A rationale
While placing pillows inside the side rails can prevent injury, it may not be effective if the child is having a severe tonic-clonic seizure, as the child could still injure themselves. Padding the entire bed with approved padding is more appropriate in such a case.
Choice B rationale
During a seizure, it is crucial to ensure the child’s safety by asking the mother to release the child to prevent unintentional injury. Holding the child down during a seizure can cause harm to both the child and the mother, and it's important to provide a safe space for the child to move.
Choice C rationale
Administering an anticonvulsant medication can help control the seizure and prevent further convulsions. Medications such as benzodiazepines are often used to treat ongoing seizures and can provide rapid relief.
Choice D rationale
Closing the blinds to darken the room is not directly beneficial during a seizure and does not address the immediate need to protect the child from injury or manage the seizure effectively. While reducing light may help in other conditions, it is not a priority during a seizure.
Choice E rationale
Monitoring the child's airway and tongue is critical to ensure they are not at risk of choking or aspiration during a seizure. Keeping the airway clear and observing for any obstructions can prevent further complications and ensure the child’s safety.
Correct Answer is C
Explanation
Choice A rationale
Gathering supplies for an IV infusion is essential in many cases but not the priority here. Measuring abdominal circumference helps determine if there is abdominal distention indicating a possible blockage, which could suggest a condition like Hirschsprung's disease. Early detection and appropriate intervention are critical, making it the first action.
Choice B rationale
Preparing for anorectal surgery may be necessary if a diagnosis like Hirschsprung’s disease or imperforate anus is confirmed. However, the initial priority is to assess for signs of abdominal distention by measuring the circumference, providing crucial information for the next steps.
Choice D rationale
Monitoring strict urinary output is important for overall fluid balance and identifying complications related to fluid shifts. However, in this scenario, the priority action is to assess for abdominal distention, a potential sign of a serious underlying condition causing the symptoms observed in the infant.
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