The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?
Obtain the essential information as quickly as possible.
Document interactions between the parent and the child.
Ignore the child's behavior, directing questions to a parent.
Include the child's toy in the collection of information.
The Correct Answer is D
The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuffed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When advising a new mother on caring for a child with croup, the telephone triage nurse should prioritize concern for difficulty swallowing secretions. This symptom can indicate that the child's airway is becoming obstructed and requires immediate medical attention. A fever of 101.0°F (38.3°C) is a common symptom of croup and can be managed at home with antipyretics. Crying often when nursing is not a specific symptom of croup and may have other causes. A barking cough, worse at night, is a characteristic symptom of croup and can be managed at home with humidified air and hydration.
Correct Answer is B
Explanation
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
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