A mother brings her male preschooler 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.
Explain to the child the reasons an examination is needed.
Talk to the mother and gradually focus on the child's toy.
Complete the assessment while allowing the child to cry.
The Correct Answer is C
Choice A rationale
Requesting extra staff to help with the nursing assessments may not be the most effective approach. It could increase the child's anxiety due to the presence of more unfamiliar people in the room. The primary goal is to create a calm environment that helps the child feel safe and more cooperative.
Choice B rationale
Explaining the reasons for the examination to the child may not be effective for a preschooler who may not fully understand or be comforted by such explanations. Young children often require more tangible and immediate means of reassurance and distraction.
Choice C rationale
Talking to the mother and gradually focusing on the child's toy is a practical approach. This strategy helps build rapport with both the mother and the child, and using the toy as a focal point can distract and comfort the child, making the examination process less intimidating and more cooperative.
Choice D rationale
Completing the assessment while allowing the child to cry may not be ideal. It can increase the child's distress and make the assessment more challenging. Addressing the child's emotional needs by providing comfort and distraction can lead to a more successful and less stressful examination.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The child’s symptoms suggest epiglottitis, a medical emergency requiring readiness for intubation or tracheotomy to secure the airway. Immediate preparation for these procedures is crucial to prevent airway obstruction and respiratory arrest.
Choice B rationale
Although imaging can provide diagnostic information, it is not the immediate priority. The priority is to secure the airway to prevent acute respiratory failure, making this choice less appropriate.
Choice C rationale
Nebulizer treatments can help with lower airway obstructions but are ineffective for upper airway conditions like epiglottitis. The child’s symptoms indicate upper airway obstruction, making this choice less appropriate.
Choice D rationale
While antibiotics are essential for treating infections causing epiglottitis, the immediate priority is to ensure the airway is not compromised. Securing the airway takes precedence over initiating antibiotic therapy in this acute situation.
Correct Answer is C
Explanation
Choice A rationale
Covering the lesion with a dressing is not an appropriate action as it will not prevent the transmission of herpes to the newborn. Herpes simplex virus can be transmitted to the neonate during delivery, and covering the lesion does not eliminate the risk.
Choice B rationale
Blood cultures are not indicated for managing active herpes lesions in a client with spontaneous rupture of membranes. This action does not address the immediate risk of transmission of the virus to the newborn.
Choice C rationale
Preparing for a cesarean section is the appropriate action because it reduces the risk of neonatal herpes transmission. Neonatal herpes can lead to severe complications, and a cesarean section is recommended to minimize the risk of exposure to the virus during vaginal delivery.
Choice D rationale
Administering penicillin is not appropriate for treating herpes lesions. Penicillin is an antibiotic effective against bacterial infections, but herpes is caused by a virus. Antiviral medications are required to manage herpes infections.
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