A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?
An abdominal binder can be worn daily to reduce the protrusion.
This hernia is a normal variation that resolves without treatment.
The quarter should be secured with an elastic bandage wrap.
Restrictive clothing will be adequate to help the hernia go away.
The Correct Answer is B
Choice A: An abdominal binder can be worn daily to reduce the protrusion is not a correct explanation for the nurse to provide, as this is not an effective or recommended method to treat a hernia. This is a distractor choice.
Choice B: This hernia is a normal variation that resolves without treatment is a correct explanation for the nurse to provide, as this refers to an umbilical hernia, which is a common and harmless condition in infants that usually disappears by age 2. Therefore, this is the correct choice.
Choice C: The quarter should be secured with an elastic bandage wrap is not a correct explanation for the nurse to provide, as this is a folk remedy that has no scientific basis and can cause skin irritation and infection. This is another distractor choice.
Choice D: Restrictive clothing will be adequate to help the hernia go away is not a correct explanation for the nurse to provide, as this is not a proven or safe way to treat a hernia. This is another distractor choice.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C is correct because repositioning the infant every 2 hours can help expose different parts of the skin to the phototherapy light and increase the effectiveness of the treatment. The nurse should also check the skin for signs of irritation or burns.
Choice A is incorrect because feeding the infant every 4 hours is not specific to home phototherapy. The infant may need more frequent feedings depending on their hunger cues and weight gain.
Choice B is incorrect because performing diaper changes under the light is not necessary and may expose the infant's genitals to excessive light and heat. The nurse should advise the parents to cover the infant's eyes and genitals with protective shields during phototherapy.
Choice D is incorrect because covering the infant with a receiving blanket can reduce the exposure of the skin to the phototherapy light and decrease the effectiveness of the treatment. The nurse should advise the parents to keep the infant unclothed or only in a diaper during phototherapy.
Correct Answer is B
Explanation
Choice B is correct because anxiety is the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anxiety is a feeling of fear, nervousness, or apprehension that can interfere with coping and decision making. The nurse should assess the level and source of anxiety and provide emotional support and reassurance to the client. The nurse should also review the pain management techniques and explain the benefits and risks of different analgesic options.
Choice A is incorrect because knowledge deficit is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Knowledge deficit is a lack of information or understanding about a topic or situation that can affect learning and behavior. The nurse should evaluate the client's learning needs and provide appropriate education and resources, but this is not as urgent as addressing the client's anxiety.
Choice C is incorrect because pain intolerance is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Pain intolerance is an inability or unwillingness to endure pain that can affect quality of life and recovery. The nurse should assess the client's pain level and response to analgesics and adjust the pain management plan accordingly, but this is not as urgent as addressing the client's anxiety.
Choice D is incorrect because anticipatory grieving is not the priority nursing problem for this client who starts to cry and states, "I just know I can't handle all the pain." Anticipatory grieving is a process of mourning that occurs before an expected loss or death that can affect emotional and physical well-being. The nurse should acknowledge the client's feelings and provide empathy and support, but this is not as urgent as addressing the client's anxiety.
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