The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. Which intervention should the nurse implement?

Obtain the essential information as quickly as possible.

Document interactions between the parent and the child.

Ignore the child's behavior, directing questions to a parent.

Include the child's toy in the collection of information.

Answer and Explanation

The Correct Answer is D

The nurse should implement the intervention of including the child's toy in the collection of information when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. This can help engage the child and make them feel more comfortable during the medical history collection process. The other options (A, B, and C) are not appropriate interventions in this situation.

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Correct Answer is C

Explanation

Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).

Rationale:

A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.

B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.

C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.

D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.

A. Discontinue the ointment once drainage resolves. B. Prepare the child for blurry vision after ointment application. C. Use a disposable moist wipe to remove eye crusts. D. Remove secretions by wiping toward the opposite eye.

Correct Answer is B

Explanation

When using an ophthalmic anti-infective ointment, it is important to prepare the child for blurry vision after ointment application. This is because the ointment can temporarily blur vision after application. It is important to follow the instructions on the medication label and continue using the ointment for the full course of treatment, even if symptoms improve before then ¹.

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The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuﬀed toy. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 9-week-old infant is scheduled for a cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?

Correct Answer is C

Explanation

The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inﬂamed conjunctiva. The child receives a prescription for an ophthalmic anti-infective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?

Correct Answer is B

Explanation

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