A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?
"My child still wets the bed at least two times per week."
"I have noticed that my child is withdrawn since we switched day care providers."
"I have a difficult time getting my child to eat green vegetables."
"My child continually asks me the same questions."
The Correct Answer is B
The guardian's observation about the child being withdrawn since the switch of daycare providers is particularly important. It suggests a change in behavior that could potentially indicate emotional or social difficulties.
The nurse should explore this further to gather more information and assess the child's well-being in the new daycare setting. It is essential to ensure the child's emotional health and address any potential issues that may be affecting their well-being and development.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This response allows the nurse to actively listen to the client, gain a better understanding of their concerns and reasons behind wanting to stop treatment, and open the door for a more in-depth conversation. It demonstrates a non-judgmental approach and creates an opportunity for the client to express their fears, concerns, or any other factors influencing their decision.
"I would feel the same way if I were you." This response reflects the nurse's personal opinion and may not accurately represent the client's thoughts or feelings. It does not encourage the client to explore their own feelings or provide an opportunity for open communication.
"Why do you think that would be a good choice?" This response may come across as confrontational and judgmental, potentially making the client defensive or shutting down communication. It does not facilitate a therapeutic conversation or encourage the client to express their emotions and concerns openly.
"You'll be cancer-free after you complete your treatments." This response may oversimplify the client's situation or offer false reassurance. It is important to acknowledge the client's feelings and concerns while providing accurate information and support, rather than making unrealistic promises about treatment outcomes.
The nurse should approach the client's expression of wanting to stop treatment with empathy, active listening, and an open mind to provide the necessary support, education, and resources to help the client make informed decisions about their healthcare.
Correct Answer is A
Explanation
a. Clean the stoma using an inward to outward circular motion.
When providing tracheostomy care, the nurse should clean the stoma using an inward to outward circular motion to remove any secretions or debris. It is important to avoid using excessive force or pressure, which can cause trauma to the stoma. Cleansing the inner cannula with isopropyl alcohol may be appropriate for some clients, but it is important to follow the healthcare provider's orders regarding inner cannula care.
When securing the tracheostomy ties, the nurse should ensure that there is enough space for two fingers, not three. Finally, the nurse should prepare sterile supplies before removing the inner cannula to ensure that they are readily available and reduce the risk of infection.
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