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 A
Explanation
A. While monitoring for increased intracranial pressure is important, measuring head circumference every shift may not be necessary unless there is a specific indication or change in the child's condition.
B. Admitting the child to a private room is necessary to reduce the risk of spreading the infection to others.
C. Placing the child in a semi-Fowler's position can help reduce intracranial pressure and promote comfort.
D. Implementing seizure precautions is important, as children with bacterial meningitis are at risk for seizures.
Correct Answer is A
Explanation
A. Nurses are mandated reporters of child abuse, and informing the parent about the legal obligation to report is appropriate and transparent.
B. Reporting to a supervisor does not relieve the nurse of the responsibility to directly report suspected child abuse to the appropriate authorities.
C. While the nurse should be empathetic, the legal obligation to report takes precedence over discussing details with the parent.
D. In situations of suspected child abuse, it is the responsibility of the nurse, not the provider, to make the initial report.
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