A nurse is caring for a 10-year-old boy who has a new diagnosis of diabetes mellitus and is eager to return to school and participate in social events. The mother tells the nurse she is afraid to let him take part in physical activities at school. Which of the following responses should the nurse make?
You sound overwhelmed. Let’s talk about this some more.
I agree. His well-being is the most important.
Tell me more about how you are feeling about your son’s activities.
You might want to use tutors to home-school him.
The Correct Answer is C
Choice A reason: You sound overwhelmed. Let’s talk about this some more. This response acknowledges the mother’s feelings and opens the door for further discussion. However, it does not directly address her specific concerns about physical activities. While it is empathetic, it lacks the focus needed to explore her worries about her son’s participation in school activities.
Choice B reason: I agree. His well-being is the most important. This response validates the mother’s concern but may inadvertently reinforce her fears without providing a balanced perspective. It does not encourage a discussion about the benefits of physical activity for children with diabetes or how to manage his condition safely during such activities.
Choice C reason: Tell me more about how you are feeling about your son’s activities. This response is the most appropriate as it invites the mother to express her specific concerns and feelings. It shows empathy and a willingness to understand her perspective, which can lead to a more productive conversation about managing her son’s diabetes while allowing him to participate in physical activities.
Choice D reason: You might want to use tutors to home-school him. This response suggests an alternative that may not be necessary or beneficial. Home-schooling might isolate the child and prevent him from enjoying social interactions and physical activities that are important for his overall development. It does not address the mother’s concerns directly and may not be the best solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Taking aspirin while on prednisone can increase the risk of gastrointestinal bleeding. Prednisone, a corticosteroid, can cause stomach irritation, and combining it with aspirin, a nonsteroidal anti-inflammatory drug (NSAID), can exacerbate this effect. Therefore, clients should avoid taking aspirin for minor aches and pains while on prednisone.
Choice B reason: A sore throat is not a common side effect of prednisone. Prednisone can suppress the immune system, making clients more susceptible to infections, but it does not typically cause a sore throat within the first week of use. If a client experiences a sore throat, they should contact their healthcare provider as it may indicate an infection.
Choice C reason: Clients on prednisone should avoid live vaccines, such as the flu vaccine, within one week of starting the medication. Prednisone can weaken the immune system, reducing the effectiveness of the vaccine and increasing the risk of developing the illness the vaccine is meant to prevent. It is generally recommended to consult with a healthcare provider before receiving any vaccines while on prednisone.
Choice D reason: Prednisone can cause potassium loss, leading to hypokalemia. Eating more bananas, which are high in potassium, can help counteract this effect and maintain normal potassium levels. Normal potassium levels range from 3.5 to 5.0 mEq/L. Therefore, clients should increase their intake of potassium-rich foods like bananas while taking prednisone.
Correct Answer is A
Explanation
Choice A reason:
Decreasing the infusion rate is the appropriate action when a client experiences flushing and tachycardia while receiving IV vancomycin. These symptoms are indicative of “Red Man Syndrome,” a reaction that occurs when vancomycin is infused too quickly. Slowing the infusion rate can help alleviate these symptoms and prevent further complications.
Choice B reason:
Changing the IV infusion site is not necessary in this situation. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of administration. Therefore, changing the site would not address the underlying issue.
Choice C reason:
Documenting that the client experienced an anaphylactic reaction to the medication is incorrect. Anaphylaxis is a severe, life-threatening allergic reaction that involves symptoms such as difficulty breathing, swelling of the face and throat, and a rapid drop in blood pressure. The symptoms described (flushing and tachycardia) are more consistent with Red Man Syndrome, not anaphylaxis.
Choice D reason:
Applying cold compresses to the neck area is not an effective intervention for managing the symptoms of Red Man Syndrome. The primary approach should be to slow the infusion rate of vancomycin. Cold compresses would not address the cause of the reaction.
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