A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?
"Does your child seem mentally slower than his peers also?"
"Haven't you been feeding him according to recommended daily allowances for children?"
"His smaller size is probably due to the heart disease."
"You should not worry about the growth tables. They are only averages for children."
The Correct Answer is C
In this scenario, the child with a congenital heart defect is presenting with a fever and an
earache. The mother expresses concern about the child's weight and height being at the 5th percentile for his age. Given the child's medical history of a congenital heart defect, it is important for the nurse to address the mother's concerns and provide an accurate response.
The response that states "His smaller size is probably due to the heart disease" is appropriate because children with congenital heart defects may experience growth and developmental delays. Heart defects can affect the child's ability to obtain sufficient nutrients for growth, leading to slower weight and height gain. By acknowledging the relationship between the child's heart disease and his smaller size, the nurse provides the mother with an explanation for the child's growth pattern and helps alleviate concerns.
The other response options are not appropriate or helpful. Asking about the child's mental abilities or implying that the mother has not been feeding the child adequately can be perceived as judgmental or dismissive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["9"]
Explanation
Here are the steps you can follow to calculate the infusion pump flow rate:
Step 1: Calculate the prescribed dose in mcg/min
- Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min
Step 2: Convert the concentration in the IV bag to mcg/mL
- Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
- Concentration: 200,000 mcg / 250 mL = 800 mcg/mL
Step 3: Calculate the flow rate in mL/min
- Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min
Step 4: Convert the flow rate to mL/hour
- Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour
Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.
Correct Answer is D
Explanation
Choice A rationale: White blood cell count monitors for infection or inflammation. While important for general health, it does not address the massive fluid loss and electrolyte imbalances specifically caused by diabetes insipidus.
Choice B rationale: Capillary glucose monitors for diabetes mellitus. Diabetes insipidus involves antidiuretic hormone deficiency, not insulin issues; therefore, glucose levels are not the priority in managing the massive dilute polyuria seen here.
Choice C rationale: Urine specific gravity will be consistently low in diabetes insipidus. While it confirms the diagnosis of dilute urine, it is less critical than monitoring the life-threatening systemic effects of dehydration.
Choice D rationale: Serum sodium is the most important lab to monitor. Massive loss of dilute urine leads to severe hemoconcentration and hypernatremia, which can cause cerebral edema, seizures, and permanent neurological damage.
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