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 B
Explanation
When moving an adolescent with scoliosis who is recovering after a surgical spinal instrumentation, the nurse should use the log roll technique. This technique involves keeping the spine in alignment while turning the client onto their side. Crossing the arms and legs, raising the hips, and flexing the knees are not appropriate techniques for moving a client with spinal instrumentation.
Correct Answer is D
Explanation
If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks
A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings
B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination
C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.
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