The mother of a 4-year-old boy tells the nurse that her son occasionally wets his pants during the day. How should the nurse respond?

"Tell me about the circumstances when this occurs."

"Is there a family history of diabetes?"

"Suddenly having accidents can be a sign of diabetes."

"That's normal: don't worry about it."

Answer and Explanation

The Correct Answer is A

A. "Tell me about the circumstances when this occurs.": This response allows the nurse to gather more information about the child's toileting habits and potential triggers for the accidents.

Understanding the context can help identify possible underlying causes and guide appropriate interventions.

B. "Is there a family history of diabetes?": While diabetes can be a cause of increased urination, asking about a family history of diabetes is premature and may unnecessarily alarm the parent before further assessment.

C. "Suddenly having accidents can be a sign of diabetes.": Jumping to conclusions about a serious medical condition like diabetes without further assessment or evidence can cause unnecessary anxiety for the parent. It's important to gather more information and consider other potential causes before suggesting a diagnosis.

D. "That's normal: don't worry about it.": While occasional daytime wetting accidents can be common in young children, dismissing the concern without further assessment may overlook potential underlying issues that could benefit from intervention or support.

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Correct Answer is B

Explanation

A. Wash the hands and breasts thoroughly prior to breastfeeding: While hand hygiene is

important, washing the breasts thoroughly before breastfeeding is not recommended as it can remove natural oils that protect the skin and may cause irritation.

B. Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areolA. This is a recommended guideline for proper latching during breastfeeding. Ensuring that the baby's mouth covers both the nipple and the surrounding areola helps to facilitate effective milk transfer and prevents nipple pain or damage.

C. When finished, the mother can break the suction by firmly pulling the baby's mouth away from the nipplE. Breaking the suction by pulling the baby's mouth away can cause nipple

trauma. Instead, it's recommended to insert a clean finger into the corner of the baby's mouth to break the suction before removing the baby from the breast.

D. Stroke the nipple against the baby's chin to stimulate wide opening of the baby's mouth: This action may not effectively stimulate the baby to open wide and latch properly. It's better to use gentle pressure on the baby's chin or lower lip to encourage a wider latch

A. Body weight B. Skin integrity C. Respiratory rate D. Blood pressure

Correct Answer is A

Explanation

A. Body weight: Body weight is the most reliable indicator of fluid loss, as changes in weight directly reflect changes in fluid balance. Monitoring weight is essential for assessing dehydration and guiding fluid replacement therapy.

B. Skin integrity: While changes in skin turgor and skin integrity can be indicators of

dehydration, they are less reliable in infants, especially if they have certain skin conditions or are very young.

C. Respiratory ratE. Although increased respiratory rate can occur as a compensatory mechanism for metabolic acidosis associated with dehydration, it is not as reliable as changes in body weight for assessing fluid loss.

D. Blood pressurE. While blood pressure may be affected by severe dehydration, it is not as sensitive or practical as monitoring body weight for assessing fluid loss in infants.

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The mother of a 4-year-old boy tells the nurse that her son occasionally wets his pants during the day. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which is a recommended guideline that should be implemented?

Correct Answer is B

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is A

Explanation

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