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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of lung tissue and loss of elasticity in the alveoli. This leads to poor gas exchange, specifically the reduced ability of oxygen to enter the bloodstream and carbon dioxide to be eliminated from the body. Impaired gas exchange can result in hypoxemia and hypercapnia, leading to symptoms such as shortness of breath, fatigue, and decreased exercise tolerance.
While self-care deficit, activity intolerance, and ineffective airway clearance are all potential complications associated with emphysema, impaired gas exchange is the priority due to its direct impact on the client's oxygenation and overall respiratory function.
Addressing impaired gas exchange and optimizing oxygenation is essential to support the client's respiratory health and prevent further complications. Management strategies for impaired gas exchange may include administering supplemental oxygen, implementing respiratory treatments to improve lung function, and providing education on breathing techniques and energy conservation.
Correct Answer is C
Explanation
The correct answer is Choice C: “This must be a very difficult time for you.”
Choice A rationale: Telling the parent “You didn’t do anything wrong” might seem comforting, but it doesn’t address the parent’s feelings of guilt or responsibility.It’s important to remember that myelomeningocele is a birth defect that occurs when the spine and spinal cord do not develop completely1.It’s often not known why this happens, but it can be due to a combination of genetic and environmental factors2. Therefore, it’s not something the parent did or didn’t do.
Choice B rationale: Asking “Is there any particular reason why you think this is your fault?” could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It’s crucial to approach this situation with empathy and understanding, acknowledging the parent’s feelings without making them feel judged.
Choice C rationale: Saying “This must be a very difficult time for you” is the most helpful response because it acknowledges the parent’s feelings and offers empathy. It doesn’t place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.
Choice D rationale: While it’s true that surgery can help manage the condition1, saying “With surgery, your baby should have a full recovery” might be misleading.Myelomeningocele is the most severe form of spina bifida and can cause moderate to severe disabilities, such as muscle weakness, loss of bladder or bowel control, and/or paralysis2. Each case is unique, and while some children may have less severe symptoms, others may require lifelong management. It’s important to provide accurate and realistic information.
Remember, it’s essential to approach these conversations with empathy and understanding. Parents dealing with a diagnosis of myelomeningocele are likely experiencing a range of emotions, and they need support and accurate information.
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