A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, "I don't know what to do because they're not eating." Which of the following responses should the nurse make?
"I'm sure it's nothing serious and their appetite will return soon."
"Tell me more about what happens at mealtime."
"Why do you think they're not eating?"
"They may need a feeding tube."
The Correct Answer is B
Choice A Reason:
"I'm sure it's nothing serious and their appetite will return soon." Is incorrect. This response dismisses the concern without addressing the underlying issue. It might overlook potential reasons for the lack of appetite and could lead to neglecting a serious problem.
Given the concern about the client not eating, the most appropriate response for the nurse to make would be:
Choice B Reason:
"Tell me more about what happens at mealtime." Is correct. This response encourages the child to share specific details about the mealtime routine, any challenges, or reasons behind the lack of eating. It allows the nurse to gather more information, identify potential issues, and offer appropriate guidance or interventions. Understanding the context surrounding the eating habits can help determine the best approach to address the situation effectively.
Choice C Reason:
"Why do you think they're not eating?" is incorrect. While it encourages discussion, this response puts the responsibility on the child to provide explanations that they might not fully understand or be equipped to articulate. It's essential for the nurse to gather information but in a more supportive and guiding manner.
Choice D Reason:
"They may need a feeding tube." Is incorrect. Jumping to a conclusion about a feeding tube without gathering more information or exploring other possibilities could alarm the child unnecessarily. This response could also create unnecessary worry for the child and the family without assessing the situation comprehensively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
"I might have headaches due to a decline in my estrogen levels." Is appropriate. During perimenopause, fluctuations and eventual decline in estrogen levels can contribute to various symptoms, including headaches or migraines, due to hormonal changes. This statement reflects an awareness of one of the possible effects of changing hormone levels during this stage.
Choice B Reason:
"The best time to perform a breast self-examination is on the first day of my period." Is not appropriate. While performing a breast self-examination regularly is essential for breast health, the first day of the period isn't necessarily the "best" time for everyone. It's more advisable to choose a consistent day each month that is convenient and easy to remember.
Choice C Reason:
"I can expect to have regular periods until I am in menopause." Is not appropriate. Perimenopause is characterized by irregular periods, which means that during this transitional phase, menstrual cycles often become less predictable in terms of timing, duration, and flow. Irregular periods are a hallmark of perimenopause, so expecting regularity until menopause is not accurate.
Choice D Reason:
"I should stop receiving Papanicolaou tests once I reach menopause." Is not appropriate. Papanicolaou (Pap) tests are essential for detecting cervical abnormalities, regardless of menopausal status. Women should continue to have regular Pap tests according to their healthcare provider's recommendations, as the risk of cervical cancer persists even after menopause.
Correct Answer is A
Explanation
Choice A Reason:
Measuring the intake and output of a client who has received furosemide is correct. This task involves recording and measuring fluid intake and output, which is typically within the scope of practice for assistive personnel. It requires accurate documentation and doesn't involve making clinical judgments.
Choice B Reason:
Reinforcing teaching with a client about crutch-gait walking is incorrect. Teaching and instructing clients about specific medical procedures or techniques usually require specialized knowledge and assessment skills, typically within the nurse's scope of practice.
Choice C Reason:
Checking a client's peripheral IV site for redness or swelling is incorrect. Assessing for redness or swelling at an IV site involves clinical judgment and assessment skills to identify potential complications. This task is better suited for a licensed nurse who can interpret findings and take appropriate action if needed.
Choice D Reason:
Assessing the pain level of a client who has received acetaminophen is incorrect. Assessing pain levels involves subjective interpretation and understanding of pain scales, which generally falls under the scope of licensed healthcare providers who can evaluate and manage pain interventions based on assessments.
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