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 C
Explanation
Choice A Reason:
Have the client sign an against medical advice (AMA) form is incorrect. While this form allows patients to leave against medical advice after acknowledging the risks, it should be used after thorough discussion, ensuring the patient understands the consequences. In this case, the client is postoperative and might not have received clearance from the surgeon, so this option may not be appropriate without further assessment.
Choice B Reason:
Tell the client that the surgeon will prescribe restraints if they try to leave is incorrect. Threatening restraints is not a suitable or ethical approach. Using restraints should be a last resort for ensuring safety, especially if a patient is attempting to leave. It's crucial to communicate and engage in dialogue rather than resorting to threats or coercion.
Choice C Reason:
Explain to the client that they cannot leave until the surgeon discharges them is correct. This action prioritizes the safety and well-being of the client while also informing them of the necessary procedure before leaving the hospital. It's essential to communicate the discharge process and ensure that the client understands the potential risks of leaving without proper medical approval. This approach maintains respect for the client's autonomy while emphasizing the importance of following the medical protocol for a safe recovery.
Choice D Reason:
Administer a sedative medication to the client is incorrect. Using sedatives to prevent a patient from leaving is not ethically or medically appropriate unless there's a critical situation where the patient is a danger to themselves or others. Administering sedatives without proper justification or consent violates ethical principles and could potentially harm the patient.
Correct Answer is B
Explanation
Choice A Reason:
"Aren't you interested in learning how to perform this test?" is incorrect. This response might come across as accusatory or judgmental, potentially making the client feel uncomfortable or defensive, further hindering communication.
Choice B Reason:
"Let's talk about what you're thinking." Is correct. This response acknowledges the client's distraction and aims to understand and address their thoughts or concerns that might be hindering their focus. It invites the client to express any worries or questions they might have, allowing the nurse to provide reassurance or clarification.
Choice C Reason:
"I'll discuss this with your partner instead." Is incorrect. Redirecting the conversation to the client's partner without understanding the client's concerns directly could undermine the client's autonomy and miss the opportunity to address their needs.
Choice D Reason:
"Is this something you think you can do?" is incorrect. While this question aims to assess the client's confidence, it might not effectively address the underlying reason for the client's distraction or encourage open communication about their concerns.
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