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 A
Explanation
A) Correct- Zidovudine is an antiretroviral medication used in the treatment of HIV infection.
One of the potential side effects of zidovudine is hematological toxicity, including anemia (low red blood cell count) and neutropenia (low white blood cell count). The appearance of pinpoint, red, round spots on the skin could be indicative of petechiae, which are small hemorrhages caused by the leakage of blood into the skin. Petechiae can occur due to low platelet counts, a
component of the complete blood count (CBC). Monitoring the complete blood count is important for clients receiving zidovudine to identify any potential adverse effects on blood cell counts. Anemia and neutropenia can increase the risk of infection, bleeding, and other complications. Therefore, any changes in blood cell counts, including the presence of petechiae, should be reported to the healthcare provider for further evaluation and management.
B) Incorrect- This is used to assess allergic reactions and is not specifically related to the appearance of petechiae.
C) Incorrect- A skin biopsy is typically performed to diagnose skin conditions or diseases and is not the primary assessment to evaluate the cause of petechiae.
D) Incorrect- Electromyography is a diagnostic test used to assess muscle and nerve function and is not relevant to the appearance of petechiae associated with zidovudine use.
Correct Answer is C
Explanation
The property of the drugs that, if shared by both, indicates a need to closely monitor the client for drug toxicity is:
Highly protein bound.
When a drug is highly protein bound, it means that a significant portion of the drug molecules bind to proteins in the bloodstream. This binding can affect the availability and distribution of the drug in the body. If two drugs are highly protein bound and administered together, they may compete for binding sites on the proteins, leading to increased levels of unbound (free) drug in the bloodstream. This can result in higher drug concentrations and an increased risk of drug toxicity.
Closely monitoring the client for drug toxicity is necessary when drugs are highly protein bound because there is a potential for increased drug levels and associated adverse effects. Monitoring for signs and symptoms of drug toxicity, as well as routine laboratory tests to assess liver and kidney function, may be necessary in these cases.
The other properties listed do not necessarily indicate a need for closer monitoring for drug toxicity:
- Low bioavailability refers to the fraction of an administered dose that reaches the systemic circulation in an active form. While low bioavailability can affect the effectiveness of a drug, it does not directly imply a need for closer monitoring for drug toxicity.
- Short half-life refers to the time it takes for half of the drug concentration in the body to be eliminated. While drugs with short half-lives may require more frequent dosing, this property does not inherently suggest a need for closer monitoring for drug toxicity.
- High therapeutic index indicates a wide margin of safety for a drug, meaning that the effective dose is significantly lower than the toxic dose. A high therapeutic index implies that the drug has a wide safety margin and is less likely to cause drug toxicity.
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