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:
Impaired physical mobility relative to muscle rigidity has the highest priority in the nursing care plan for a client diagnosed with Parkinson's disease. Parkinson's disease is characterized by motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Impaired physical mobility can significantly impact a patient's ability to perform activities of daily living and maintain independence. Addressing this issue is crucial to enhance the patient's quality of life and prevent complications such as falls.
Choice B rationale:
While the risk for aspiration relative to muscle weakness is a valid concern in Parkinson's disease, impaired physical mobility takes precedence as it directly affects the patient's ability to move, ambulate, and perform daily activities. Addressing mobility issues is fundamental to maintaining overall functioning and independence.
Choice C rationale:
The risk for constipation relative to immobility is important to address, but it is not the highest priority. Impaired physical mobility can lead to multiple complications, including constipation. However, improving mobility should be the primary focus to prevent a wide range of issues associated with Parkinson's disease.
Choice D rationale:
Self-care deficit relative to motor disturbance is a concern in Parkinson's disease, but it is not the highest priority. Impaired physical mobility directly impacts a patient's ability to engage in self-care activities. By addressing mobility issues first, the nurse can facilitate the patient's ability to perform self-care tasks more independently in the long run.
Correct Answer is C
Explanation
Choice A rationale:
Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.
Choice B rationale:
Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.
Choice C rationale:
Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.
Choice D rationale:
Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.
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