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 A

Explanation

In a normal infant, T4 levels increase after birth due to stimulation by TSH from the pituitary gland. In this case, the T4 level is low and the TSH level is high, indicating that the thyroid gland is not producing enough T4 in response to TSH stimulation. This suggests that the infant may have congenital hypothyroidism, which requires prompt treatment to prevent developmental delays and other complications.

The low T4 level is not a direct cause of the high TSH level; rather, the high TSH level is a compensatory mechanism to increase T4 production. It is not normal for a breastfeeding infant to have high thyroxine levels. While the thyroid gland may take a few weeks to reach normal function after birth, the persistent low T4 and high TSH levels in this infant suggest a more serious issue.

A. Ask the boy to describe a typical day at school. B. Compare the child's vital signs over the past three weeks. C. Conduct a complete neurological assessment. D. Counsel the parents to pay more attention to the child.

Correct Answer is A

Explanation

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.

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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 breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

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