A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Explain to the child the reasons an examination is needed.

Talk to the parent and gradually focus on the child's toy.

Complete the assessment while allowing the child to cry.

Request extra staff to help with the nursing assessments.

Answer and Explanation

The Correct Answer is B

A. Explaining the exam: Preschool-aged children might not fully understand the need for an exam, and this might not alleviate their anxiety.

B. Talking to parent and focusing on toy: This strategy prioritizes calming the child first. Talking to the parent helps gather information while the nurse gradually gains the child's trust by acknowledging their toy. This can create a more positive and collaborative environment.

C. Completing assessment while crying: This can be stressful for the child and might hinder an accurate assessment.

D. Requesting extra staff: While additional support might be helpful, the initial approach should focus on building rapport with the child.

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Correct Answer is ["9"]

Explanation

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

A. Blood urea nitrogen (BUN). B. Glucose. C. White blood cell count (WBC). D. Hematocrit.

Correct Answer is D

Explanation

A. Blood urea nitrogen (BUN): Elevated BUN can indicate kidney problems, but it's not the primary test for melena (black, tarry stools) which suggests upper gastrointestinal bleeding.

B. Glucose: Glucose levels might be abnormal in some conditions that can cause bleeding, but it's not the most specific test for melena.

C. White blood cell count (WBC): WBC might be elevated in response to infection or inflammation, but it's not the most specific test for melena.

D. Hematocrit: Hematocrit measures the percentage of red blood cells in the blood. Melena can indicate significant blood loss, and monitoring hematocrit helps assess the severity of bleeding and potential need for blood transfusions.

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A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["9"]

Explanation

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is D

Explanation

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

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