A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, “I don’t understand why my child is so upset. I’ve never seen my child act this way around others before.” Which of the following statements should the nurse make?
“This is a normal, expected reaction for a child of this age.”
“This is a response to an overstimulating environment.”
“This is a common reaction to an overexposure to caregivers.”
“This is a typical reaction for a child who is sick.”
The Correct Answer is A
A. Separation anxiety is a normal developmental milestone that typically peaks around 8 months of age. It is a sign of healthy attachment and is expected during this stage of infancy.
B. While overstimulation can cause distress in some children, the scenario presented is more indicative of separation anxiety.
C. Overexposure to caregivers is not a recognized cause of the described behavior. Instead, it is a manifestation of the child's attachment to the primary caregiver.
D. The behavior described is more consistent with separation anxiety than illness. Illness-related distress would likely involve other signs and symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Deep, rapid respirations (Kussmaul respirations) are more commonly associated with diabetic ketoacidosis, not hypoglycemia.
B. Tachycardia is a common response to hypoglycemia as the body attempts to compensate for low blood glucose levels.
C. Polyuria is more characteristic of hyperglycemia and diabetes mellitus, not hypoglycemia.
D. Dry flushed skin is not a typical manifestation of hypoglycemia. It may occur with hyperglycemia or dehydration.
Correct Answer is B
Explanation
A. Projectile vomiting in an infant could be indicative of a serious condition, and advising on burping may not be sufficient. A prompt assessment by a healthcare provider is needed.
B. Projectile vomiting can be a concerning sign and may be associated with conditions such as pyloric stenosis. Bringing the baby to the clinic for evaluation is the appropriate action.
C. Switching formula may not address the underlying cause of projectile vomiting, and it is crucial to determine the cause through a thorough examination.
D. While oral rehydration solution may be used for dehydration, the priority is to assess the infant in person to determine the cause of the vomiting.
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