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 D
Explanation
Choice A Reason:
Placing the bed in the lowest position before logrolling the client is incorrect. Lowering the bed position isn't directly related to the safety or comfort of the client during logrolling. It's more important to focus on proper body alignment and support for the surgical site.
Choice B Reason:
Placing the client in semi-Fowler's position prior to logrolling is incorrect. Semi-Fowler's position (a reclined position with the head of the bed elevated at a 30-45-degree angle) might be used for comfort, but it's not specifically necessary before logrolling, which is a technique used to move the client while maintaining spinal alignment.
Choice C Reason:
Placing the client's arms above her head prior to logrolling is incorrect. Placing the client's arms above the head isn't typically necessary or recommended before logrolling a postoperative client. It's crucial to prioritize maintaining proper body alignment and minimizing stress on the surgical site during movement.
Choice D Reason:
Placing a pillow between the client's legs prior to logrolling is correct. This action helps maintain proper alignment of the spine and reduces pressure on the surgical site during logrolling. Placing a pillow between the legs provides support and helps prevent excessive twisting or stress on the back.
Correct Answer is D
Explanation
Choice A Reason:
"Encourage your partner to eat three large meals each day." Is incorrect. At the end of life, a patient's appetite might decrease, and they may not tolerate large meals. Encouraging large meals can cause discomfort or be inappropriate for their condition.
Choice B Reason:
"We will use an electric blanket to keep your partner warm." Is incorrect. While maintaining comfort is important, the use of an electric blanket might not be suitable as the patient's circulation and ability to regulate body temperature might be compromised.
Choice C Reason:
"Opioids will be restricted if your partner develops respiratory distress." Is incorrect.
Opioids can be appropriate for managing symptoms like pain or dyspnea at the end of life. Restricting opioids solely due to the risk of respiratory distress might hinder adequate symptom management. The use of opioids should be based on individual patient needs and careful assessment by healthcare providers.
Choice D Reason:
"Assume your partner can hear you, even if they do not respond." Is correct. This statement encourages communication and acknowledges the possibility that the patient might still be able to perceive their surroundings, even if they are not responsive. It supports the importance of providing emotional support and communication during the end-of-life process.
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