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 C
Explanation
The correct answer is choice c. Inform the client that gradual tapering must be used to discontinue the medication.
Choice A rationale:
While discussing medication side effects with the healthcare provider is important, it does not address the immediate concern of discontinuing the medication safely. The nurse should provide guidance on the proper discontinuation process.
Choice B rationale:
Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.
Choice C rationale:
Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression.
Choice D rationale:
Reminding the client that feeling better is the therapeutic effect of the medication is true, but it does not address the client’s concern about discontinuing the medication safely.
Correct Answer is C
Explanation
A) Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B) Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C) Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D) Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.
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