A mother brings her male pre-schooler 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.

Complete the assessment while allowing the child to cry.

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

Explain to the child the reasons an examination is needed.

Answer and Explanation

The Correct Answer is C

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Correct Answer is C

Explanation

A.While non-pharmacologic strategies are important for pain management, they are typically introduced after initial assessment and understanding of the client's pain experience. In this case, the priority is to clarify the apparent discrepancy between the reported pain level and observed behavior.

B.Respecting the client's privacy and providing time for personal activities like phone calls is important but does not directly address the concern of incongruent pain assessment and behavior.

C.Incongruence between reported pain intensity (10/10) and observed behavior (laughing on the phone) suggests a potential discrepancy that needs to be documented and further investigated. This documentation is crucial for accurate assessment and communication among the healthcare team.

D.Administering pain medication immediately without further assessment may not be appropriate if there is uncertainty about the accuracy of the pain report. It's important to first clarify and validate the client's pain experience before proceeding with medication administration.

A. Close blinds room so is darkened. B. Ask the mother to release the child. C. Monitor the child's airway and tongue. D. Administer an anticonvulsant medication. E. Place pillows inside the side rails.

Correct Answer is ["B","C","E"]

Explanation

A. Closing the blinds room so is darkened is inappropriate. The lighting in the room is unlikely to have an impact on the seizure or its management. Ensuring safety and maintaining the airway is the priority.

B.Asking the mother to release the child is appropriate. It’s important to ensure the safety of both the child and the mother. The mother should be asked to release the child to prevent any potential harm to the child during the seizure

C. Monitoring the child's airway and tongue is appropriate. During a seizure, there is a risk of the child's airway being compromised. The nurse should closely monitor the child's airway to ensure that it remains open and that the tongue does not obstruct the airway. Positioning the child on their side can also help prevent choking.

D. Administering an anticonvulsant medication is inappropriate. The nurse should not administer medication without a healthcare provider's order. In a seizure emergency, the focus is on maintaining safety and managing the seizure itself.

E. Place pillows inside the side rails: This is a correct action to prevent injury during the seizure. Padding the side rails helps protect the child from hitting their head or limbs on the hard surfaces.

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A mother brings her male pre-schooler 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent hospitalized with sickle cell anaemia reports to the nurse of experiencing a pain level of 10 on a 0 to 10 numerical scale. The nurse observes the adolescent on a phone call laughing. Which action should the nurse take?

Correct Answer is C

Explanation

A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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