A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?
"Does your child seem mentally slower than his peers also?"
"Haven't you been feeding him according to recommended daily allowances for children?"
"His smaller size is probably due to the heart disease."
"You should not worry about the growth tables. They are only averages for children."
The Correct Answer is C
In this scenario, the child with a congenital heart defect is presenting with a fever and an
earache. The mother expresses concern about the child's weight and height being at the 5th percentile for his age. Given the child's medical history of a congenital heart defect, it is important for the nurse to address the mother's concerns and provide an accurate response.
The response that states "His smaller size is probably due to the heart disease" is appropriate because children with congenital heart defects may experience growth and developmental delays. Heart defects can affect the child's ability to obtain sufficient nutrients for growth, leading to slower weight and height gain. By acknowledging the relationship between the child's heart disease and his smaller size, the nurse provides the mother with an explanation for the child's growth pattern and helps alleviate concerns.
The other response options are not appropriate or helpful. Asking about the child's mental abilities or implying that the mother has not been feeding the child adequately can be perceived as judgmental or dismissive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.
Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.
Correct Answer is A
Explanation
The presenting symptoms of the infant, including persistent vomiting, poor skin turgor, significant weight loss, and a palpable abdominal mass, indicate a potential serious condition that requires immediate attention. These findings may suggest dehydration, malnutrition, and the presence of an abdominal mass that could be causing gastrointestinal obstruction or other underlying pathology.
Initiating a prescribed IV for parenteral fluid is the priority intervention to address the potential dehydration and fluid imbalance in the infant. This will help restore and maintain adequate hydration while further diagnostic evaluations and interventions are initiated.
Feeding the infant, giving 5% dextrose in water orally, or inserting a nasogastric tube for feeding should not be implemented as the first intervention in this case. It is important to stabilize the infant's fluid status before initiating oral feedings or other interventions to address the underlying cause of the symptoms.
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