Nokea
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?
- A. Obtain the essential information as quickly as possible.
- B. Document interactions between the parent and the child.
- C. Ignore the child's behavior, directing questions to a parent.
- D. Include the child's toy in the collection of information.
Correct Answer: D
Rationale: Including the child's toy can comfort and engage the child, facilitating a more effective medical history collection.
You may also like to solve these questions
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the healthcare provider is notified?
- A. Digoxin.
- B. Furosemide.
- C. Hydralazine.
- D. Enalapril.
Correct Answer: A
Rationale: Digoxin should be withheld if the apical pulse is below 90 beats/minute in infants, as it may indicate toxicity.
While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx.
- B. Touch the tonsillar pillars to stimulate the gag reflex.
- C. Ask the child to speak to evaluate change in voice tone.
- D. Assess for teeth clenching or grinding.
Correct Answer: A
Rationale: Frequent swallowing may indicate postoperative bleeding, so inspecting the oropharynx is critical.
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
- B. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- C. Administer the injection into the middle of the lateral aspect of the thigh.
- D. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
Correct Answer: C
Rationale: The lateral thigh is the recommended IM injection site for toddlers, minimizing nerve and vessel damage.
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?
- 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: B
Rationale: Ophthalmic ointment can cause temporary blurry vision, and preparing the child for this effect is important.
A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Reactions to any previous hospitalizations.
- C. A history of rubella, rubeola, or chicken pox.
- D. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
Correct Answer: B
Rationale: Previous hospitalization reactions help anticipate and address fears, aiding in care planning.