A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?
"Haven't you been feeding according to recommended daily allowances for children?"
"Does your child seem mentally slower than his peers also?"
"You should not worry about the growth tables. They are only averages for children."
"The smaller size is probably due to the heart disease."
The Correct Answer is D
A. "Haven't you been feeding according to recommended daily allowances for children?": This response implies blame and lacks sensitivity. It doesn't acknowledge the child’s underlying medical condition that may affect growth.
B. "Does your child seem mentally slower than his peers also?": Intellectual development is unrelated to height/weight percentile in children with congenital heart disease unless there are neurological complications, which haven't been indicated.
C. "You should not worry about the growth tables. They are only averages for children.": While growth charts are averages, they are clinically significant, especially for identifying underdevelopment in children with chronic illnesses.
D. "The smaller size is probably due to the heart disease.": Chronic hypoxia and increased metabolic demands in congenital heart disease often contribute to poor weight gain and growth delay, making this the most informative and empathetic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,D,C
Explanation
1. B. Verify the insulin prescription: The first step is to verify the prescription to ensure the correct type and dose of insulin before administering it. This ensures one is following the appropriate instructions.
2. A. Obtain blood glucose level: The next step is to check the client's blood glucose level to determine the amount of insulin needed based on the sliding scale.
3. D. Cleanse the selected site: After obtaining the blood glucose level, the next step is to prepare the injection site by cleaning it properly to prevent infection.
4. C. Draw insulin into insulin syringe: Finally, drawing the appropriate amount of insulin into the syringe, based on the sliding scale and the blood glucose level, to administer the injection.
Correct Answer is B
Explanation
A. Recommend substituting opioids with other pain medication: Simply switching to another pain medication without addressing underlying misuse behaviors may reinforce dependency. This overlooks the denial and psychological aspects of addiction.
B. Explore other coping strategies aside from using medications: This client-centered approach gently addresses the issue without direct confrontation. It encourages self-reflection, promotes healthy alternatives, and meets the client where they are in terms of readiness for change, which is essential in early recovery.
C. Provide a list of local Narcotics Anonymous meetings: Although this is useful, offering it during the first interaction with a client in denial may lead to resistance. Engagement and trust-building through conversation about alternatives are more effective initially.
D. Explain that opioid abuse poses a great risk to life: Providing factual information about risk can be helpful, but directly labeling it as abuse when the client is in denial may trigger defensiveness. It is more therapeutic to explore behaviors and build insight before confrontation.
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