A nurse is assessing a 2-year-old child at a well-child visit.
The child’s parent expresses concern about the child’s increasing temper tantrums and difficult behaviors. Which of the following statements should the nurse respond with?
“Discipline is an important aspect of parenting. How do you discipline the child when they act out?”
“Some children have more difficult personalities. There are great parenting books that can help you.”.
“Toddlers are beginning to develop a desire for autonomy. Temper tantrums are normal during this stage.”.
“Diets can play a part in behavioral concerns. What does your child typically eat during the day?”
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale
While discipline is an important aspect of parenting, the nurse’s response should focus on normalizing the child’s behavior and providing reassurance to the parent. Discussing discipline methods may not address the parent’s immediate concern about temper tantrums.
Choice B rationale
Suggesting that some children have more difficult personalities and recommending parenting books may not provide the immediate reassurance and understanding the parent needs. It is important to normalize the child’s behavior and explain that temper tantrums are a normal part of development.
Choice C rationale
Toddlers are beginning to develop a sense of autonomy and independence, which can lead to temper tantrums as they assert their desires and preferences. Explaining that temper tantrums are normal during this stage of development helps reassure the parent and provides a better understanding of their child’s behavior.
Choice D rationale
While diet can play a role in behavior, the nurse’s response should focus on normalizing the child’s behavior and providing reassurance. Discussing diet may not address the parent’s immediate concern about temper tantrums and difficult behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Placing the child on a no-salt-added diet is important for managing fluid retention and hypertension in acute glomerulonephritis, but it is not the immediate priority.
Choice B rationale
Educating the parents about potential complications is essential for long-term management, but it is not the immediate priority in an acute setting.
Choice C rationale
Checking the child’s daily weight is the priority action because it helps monitor fluid balance and detect any signs of fluid retention or worsening condition. Accurate daily weight measurements are crucial for assessing the effectiveness of treatment and making necessary adjustments.
Choice D rationale
Maintaining a saline-lock is important for intravenous access, but it is not the immediate priority compared to monitoring fluid balance through daily weight checks.
Correct Answer is ["C","D","E"]
Explanation
Choice A rationale:
Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.
Choice B rationale:
Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.
Choice C rationale:
Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.
Choice D rationale:
Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.
Choice E rationale:
Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.
Choice F rationale:
Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.
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