The nurse observes an 18-month-old toddler keeping a bottle of milk in the mouth throughout the history-taking and assessment process during a well-child visit.
The mother confirms that the child has a bottle available most of the day and remarks that it makes a great pacifier.
Which response should the nurse provide?
A bottle is generally much better than using a pacifier.
The bottle will assist in preventing thumb sucking.
Prolonged bottle use can increase the risk for cavities.
Using milk rather than juice helps to avoid tooth decay.
The Correct Answer is C
Choice A rationale:
A bottle is generally much better than using a pacifier. This statement is not accurate. Prolonged bottle use, especially with sugary liquids like milk, can have adverse effects on a child's dental health. It can lead to an increased risk of cavities, similar to prolonged pacifier use.
Choice B rationale:
The bottle will assist in preventing thumb sucking. This statement is incorrect. While a bottle may provide comfort to a child, it does not prevent thumb sucking. Thumb sucking is a separate behavior that may also have dental implications if it persists beyond a certain age.
Choice C rationale:
Prolonged bottle use can increase the risk for cavities. This response is correct. Prolonged bottle use, especially with milk or sugary beverages, can expose the child's teeth to prolonged contact with sugars, increasing the risk of cavities. It's important for the nurse to educate the mother about the potential dental risks associated with extended bottle use.
Choice D rationale:
Using milk rather than juice helps to avoid tooth decay. While milk is generally considered a healthier choice than juice, the key issue in this scenario is the prolonged use of the bottle, regardless of its content. Prolonged bottle use with any liquid, including milk, can still increase the risk of cavities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Instructing the UAP to apply a warm blanket and massage the client's back is the appropriate intervention in response to the client's complaints of feeling dizzy and cold during a fecal impaction removal procedure. These symptoms suggest a vasovagal response, which can be managed by keeping the client warm and providing comfort. This intervention helps increase blood flow and alleviate symptoms.
Choice B rationale:
Inserting a gloved finger into the rectum and massaging the rectal sphincter is not the first-line intervention when a client complains of feeling dizzy and cold during a fecal impaction removal. This invasive procedure should be reserved for cases where other interventions have failed, and it is necessary to complete the impaction removal.
Choice C rationale:
Stopping the procedure and observing for a reduction in symptoms before continuing is a reasonable approach, but it does not address the immediate discomfort and distress the client is experiencing. Providing comfort measures, such as applying a warm blanket and massaging the client's back, should be the initial response.
Choice D rationale:
Encouraging the client to take slow, deep breaths while continuing the procedure may not be effective in addressing the client's symptoms of dizziness and coldness. The client may require immediate comfort measures to stabilize their condition.
Correct Answer is B
Explanation
Choice A rationale:
Tenderness is not considered a normal finding during percussion of the abdomen. Tenderness suggests an underlying issue or inflammation in the abdominal area, which requires further evaluation and investigation.
Choice B rationale:
Musical and drumlike sounds are considered normal findings during percussion of the abdomen. These sounds indicate the presence of air-filled structures like the stomach or intestines. Normal abdominal percussion sounds are tympanic, and they are characterized by a hollow, drum-like quality when the abdomen is tapped lightly. This finding suggests that there are no significant abnormalities in the abdominal area.
Choice C rationale:
Absent sounds during abdominal percussion are not considered normal and may indicate a potential problem. Absent sounds could be due to factors such as bowel obstruction or severe constipation, which require further assessment and intervention.
Choice D rationale:
Pain during abdominal percussion is not considered a normal finding. It indicates discomfort or tenderness in the abdominal area, which requires further evaluation to determine the underlying cause.
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