A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

Explain to the child the reasons an examination is needed.

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

Complete the assessment while allowing the child to cry.

Request extra staff to help with the nursing assessments.

Answer and Explanation

The Correct Answer is B

A. Explaining the exam: Preschool-aged children might not fully understand the need for an exam, and this might not alleviate their anxiety.

B. Talking to parent and focusing on toy: This strategy prioritizes calming the child first. Talking to the parent helps gather information while the nurse gradually gains the child's trust by acknowledging their toy. This can create a more positive and collaborative environment.

C. Completing assessment while crying: This can be stressful for the child and might hinder an accurate assessment.

D. Requesting extra staff: While additional support might be helpful, the initial approach should focus on building rapport with the child.

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Correct Answer is A

Explanation

A. Cries vigorously when stimulated. A vigorous cry is a positive sign that the infant's lungs are functioning well and that they are receiving adequate oxygenation, indicating a good transition to extrauterine life.

B. Heart rate of 220 beats/minute. A heart rate of 220 beats/minute is too high for a newborn and could indicate tachycardia or distress, not a normal transition.

C. A positive Babinski reflex. A positive Babinski reflex is a normal finding in newborns but is not directly related to their immediate transition to extrauterine life. It is a neurological reflex that indicates normal nervous system function.

D. Flexion of all four extremities. Flexion of all four extremities is a good sign of normal muscle tone and neurological function but does not directly indicate respiratory or circulatory adaptation to extrauterine life as clearly as a vigorous cry does.

A. Use an interpreter throughout the client's hospitalization. B. Maintain eye contact with clients when questions are asked. C. Ask the interpreter to tell the client to write down questions. D. Give the interpreter a form that lists the interview questions.

Correct Answer is B

Explanation

A. Use an interpreter throughout the client's hospitalization. Consistently using an interpreter throughout the client's hospitalization ensures clear communication, improves understanding, and enhances the quality of care. However, this answer does not address the specific context of the health assessment interview.

B. Maintain eye contact with client when questions are asked. Maintaining eye contact with the client rather than the interpreter helps build rapport and shows respect and engagement with the client. This practice encourages the client to feel directly involved in the conversation, even though an interpreter is present, fostering a sense of trust and comfort.

C. Ask the interpreter to tell the client to write down questions. This option may be less effective if the client has limited literacy or is uncomfortable with writing. Additionally, it adds an unnecessary step that can complicate the communication process.

D. Give the interpreter a form that lists the interview questions. Providing the interpreter with a list of questions might help streamline the process but can depersonalize the interaction and reduce the engagement with the client. It is more effective for the nurse to ask questions directly and maintain communication with the client.

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A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent 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

The nurse is assessing a 38-week gestation newborn infant immediately following a vaginal birth. Which assessment finding best indicates that the infant is transitioning well to extrauterine life?

Correct Answer is A

Explanation

The nurse is performing a health assessment interview with a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

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In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

A clinic nurse is assessing infants and toddlers for fine and gross motor development. Which child should the nurse refer to a healthcare provider for further evaluation?

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To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

Parents bring their 8-month-old child to the clinic because they are concerned that the child is not developing as an older sibling did. Which developmental characteristic should the nurse expect an 8-month-old to exhibit?