The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take?
Provide disposable training pants while calming the mother.
Refer the mother to a community parent education program.
Suggest that the mother consult a pediatric nephrologist.
Inform the mother that toilet training is slower for boys.
The Correct Answer is A
Choice A reason: This is correct because it addresses both the physical and emotional needs of the child and the mother. The nurse should provide comfort and reassurance to the mother and explain that occasional accidents are normal and not a sign of failure.
Choice B reason: This is incorrect because it implies that the mother is incompetent and needs external help. The nurse should first establish rapport and trust with the mother before suggesting any resources or interventions.
Choice C reason: This is incorrect because it suggests that there is something wrong with the child's kidneys, which may alarm and offend the mother. The nurse should not jump to conclusions without assessing the child's history and symptoms.
Choice D reason: This is incorrect because it generalizes and stereotypes boys as being slower than girls in toilet training. The nurse should not make assumptions based on gender and should respect individual differences.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice C is correct because observing the incision site of a client who was discharged home with a suprapubic catheter can help detect signs of infection, bleeding, or healing problems. The nurse should inspect the incision site for redness, swelling, drainage, or odor and report any abnormal findings.
Choice A is incorrect because measuring abdominal girth of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary retention or obstruction. The nurse should monitor the urine output and color and report any changes.
Choice B is incorrect because assessing perineal area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of infection or irritation. The nurse should instruct the client on how to keep the perineal area clean and dry and report any discomfort or discharge.
Choice D is incorrect because palpating flank area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary tract infection or kidney involvement. The nurse should ask the client about any pain or tenderness in the flank area and report any positive findings.
Correct Answer is D
Explanation
Choice A: Increasing oral fluids may help with hydration, but it will not reduce skin flushing caused by lisinopril. Lisinopril is an angiotensin-converting enzyme (ACE. inhibitor that dilates blood vessels and lowers blood pressure. Flushing occurs due to increased blood flow to the skin.
Choice B: Nitroglycerin is a vasodilator that relaxes smooth muscle in blood vessels and reduces chest pain caused by angina. It is not indicated for skin flushing caused by lisinopril. Moreover, nitroglycerin can lower blood pressure further and cause hypotension, headache, dizziness, and fainting.
Choice C: Going to an emergency department is not necessary for skin flushing caused by lisinopril. Flushing is not a sign of an allergic reaction or anaphylaxis, which would require immediate medical attention. Flushing is also not a symptom of a heart attack or stroke, which would present with other signs such as chest pain, shortness of breath, arm numbness, or slurred speech.
Choice D: Reassuring the client that facial flushing is a common side effect of lisinopril is the best action for the nurse to take. Flushing is not harmful or dangerous, and it usually subsides within a few hours. The nurse should explain the mechanism of action of lisinopril and its benefits for lowering blood pressure and preventing angina. The nurse should also advise the client to monitor his blood pressure regularly and report any signs of hypotension, such as dizziness, lightheadedness, or fainting.
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