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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A Reason:

Obtaining urine from the drainage bag if a urinary specimen is required is incorrect.

While obtaining urine from the drainage bag might seem practical for specimen collection, it's not the recommended method due to potential contamination of the specimen. A sterile sampling port or aspirating urine from the catheter tubing is a more appropriate technique.

Choice B Reason:

Using a catheter securing device to hold the catheter in place is correct. Securing the catheter with a proper securing device helps prevent unnecessary movement or tension on the catheter, reducing the risk of trauma to the urinary tract and ensuring stability for the catheter.

Choice C Reason:

Positioning the drainage bag higher than the client's bladder is incorrect. Positioning the drainage bag higher than the bladder can lead to backflow or reflux of urine, increasing the risk of urinary tract infections. The drainage bag should be placed below the level of the bladder to facilitate proper drainage.

Choice D Reason:

Changing the catheter bag every 3 days and as needed is incorrect. Routine changing of catheter bags every three days without clinical indication for changing can increase the risk of introducing infection. Catheter bags are changed based on clinical indications or when they are soiled or damaged, not on a fixed time schedule.

A. Decrease the volume on the hearing aid. B. Clean the hearing aid with isopropyl alcohol. C. Turn the hearing aid off for 5 min. D. Soak the hearing aid in warm water.

Correct Answer is A

Explanation

Choice A Reason:

Decreasing the volume on the hearing aid is correct. Whistling or feedback in a hearing aid can often occur due to excessive volume. Lowering the volume can help eliminate or reduce the whistling sound without disrupting the functioning of the hearing aid.

Choice B Reason:

Cleaning the hearing aid with isopropyl alcohol is incorrect. While cleaning the hearing aid is essential for maintenance, using isopropyl alcohol might not resolve the issue of whistling. It's more for general hygiene and cleanliness of the device.

Choice C Reason:

Turning the hearing aid off for 5 minutes is incorrect. Turning off the hearing aid might not address the specific issue of whistling. Additionally, it could inconvenience the client's ability to hear during that time.

Choice D Reason:

Soaking the hearing aid in warm water is incorrect. Soaking a hearing aid in water is not a recommended method, as it could damage the device and its electronic components. Water exposure might also worsen the issue instead of resolving it.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Correct Answer is A

Explanation

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