A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping.
Which intervention should the nurse implement?
Ask the boy to describe a typical day at school.
Compare the child's vital signs over the past three weeks.
Conduct a complete neurological assessment.
Counsel the parents to pay more attention to the child.
The Correct Answer is A
The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.
Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Administer the injection into the middle of the lateral aspect of the thigh is the correct choice. This is the recommended site for intramuscular injection in toddlers who have been walking for at least one month, as it is a large muscle with minimal nerves and blood vessels. Choices A, B, and D are not appropriate techniques for administering an intramuscular injection to a toddler with pneumonia.
Correct Answer is A
Explanation
Peripheral intravenous (IV) infusion is a common procedure performed on infants in a hospital setting. The selection of the IV site is critical to ensure proper placement and to prevent complications.
When starting a peripheral IV infusion on an infant, the nurse should select a site that is least restrictive to the infant. This involves selecting a site that will not restrict the infant's movement and cause discomfort. The site should be accessible, visible, and easily palpable, such as the hand, wrist, or antecubital fossa.
Assessing the dorsal surface of the feet for an IV site is not recommended as it is an area of high risk for infiltration and may restrict the infant's movement.
Instructing parents to sing or croon to the infant may provide comfort and distraction, but it is not a critical intervention when starting a peripheral IV infusion.
Applying soft restraints to all four extremities is not recommended as it may cause physical and emotional distress to the infant. It should only be used as a last resort if the infant is at high risk of self-injury or if the procedure cannot be safely performed without restraints.
Therefore, the nurse should implement the intervention of selecting a site that is least restrictive to the infant when starting a peripheral IV infusion.
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