A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make?
This is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better.
Why does it bother you that your child has wet the bed?
Your child did not seem upset, so I wouldn't worry about it if I were you.
I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me.
The Correct Answer is A
Choice A reason: This is a therapeutic response that acknowledges the parent's feelings and provides reassurance that the behavior is normal and temporary. The other responses are either dismissive, judgmental, or self-disclosing, which are not helpful for the parent.
Choice B reason: This is a judgmental response that implies that the parent is overreacting or has unrealistic expectations for their child.
Choice C reason: This is a dismissive response that minimizes the parent's concern and does not offer any support
or information.
Choice D reason: This is a self-disclosing response that shifts the focus from the parent to the nurse and does not
address the issue at hand.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This choice is correct because providing a latex-free environment is an essential intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Spina bifida is a congenital defect in which the spinal cord and its coverings do not close properly, resulting in a protrusion of the meninges (meningocele) or the meninges and spinal cord (myelomeningocele). Children who have spina bifida are at a high risk of developing a latex allergy, which can cause severe reactions such as anaphylaxis or death. Therefore, avoiding exposure to latex products such as gloves, catheters, balloons, or bandages is crucial to prevent complications.
Choice B reason: This choice is incorrect because initiating contact precautions is not necessary for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Contact precautions are infection control measures that prevent the transmission of microorganisms that can be spread by direct or indirect contact with the client or their environment. They may be indicated for clients who have multidrug-resistant organisms, clostridium difficile, or scabies, but they are not required for clients who have spina bifida unless they have a concurrent infection.
Choice C reason: This choice is incorrect because limiting visitors to immediate family members is not indicated for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Limiting visitors may be indicated for clients who have immunosuppression, isolation, or terminal illness, but it may not be beneficial for clients who have spina bifida. Allowing visitors may provide emotional and social support for the client and their family, as long as they follow standard precautions and do not pose any risk of infection or injury.
Choice D reason: This choice is incorrect because maintaining the infant in the supine position is not an appropriate intervention for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac.
Maintaining the infant in the supine position may cause pressure or trauma to the sac, which can lead to rupture, infection, or nerve damage. Therefore, positioning the infant in a prone or side-lying position with the hips flexed and knees abducted can help to protect the sac and prevent complications.
Correct Answer is B
Explanation
Choice A: A 3-year-old child is not developmentally ready to descend stairs by placing both feet on each step and holding on to the railing. A 3-year-old child can walk up stairs alternating feet with one hand held by an adult or on the railing. A 3-year-old child can also walk down stairs placing both feet on each step with one hand held by an adult.
Choice B: A 4-year-old child is developmentally able to descend stairs by placing both feet on each step and holding on to the railing. A 4-year-old child can also walk up stairs alternating feet without assistance.
Choice C: A 5-year-old child is developmentally more advanced than descending stairs by placing both feet on each step and holding on to the railing. A 5-year-old child can walk up and down stairs alternating feet without assistance.
Choice D: A 6-year-old child is developmentally more advanced than descending stairs by placing both feet on each step and holding on to the railing. A 6-year-old child can walk up and down stairs alternating feet without assistance and can also hop and skip on one foot.
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