A boy aged 4 1/2 years has been having increasingly frequent angry outbursts in preschool. He is aggressive toward the other children and the teachers. This behavior has been a problem for approximately 8-10 weeks. His parents ask the nurse for advice. What is the most appropriate intervention?
Explain that this is normal in preschoolers, especially boys.
Talk to the preschool teacher to obtain validation for the behavior the parent reports.
Refer the child for a professional psychosocial assessment.
Encourage the parent to try more consistent and firm discipline.
The Correct Answer is C
Choice A reason: This is not an appropriate intervention. Anger and aggression are not normal behaviors in preschoolers, regardless of their gender. They may indicate underlying emotional or developmental issues that need to be addressed.
Choice B reason: This is not an adequate intervention. Talking to the preschool teacher may provide some information about the child's behavior, but it does not address the root cause or offer any solutions. The nurse should collaborate with the teacher and the parents to develop a plan of care for the child.
Choice C reason: This is the most appropriate intervention. A professional psychosocial assessment can help identify the factors that contribute to the child's anger and aggression, such as family stress, trauma, mental health problems, or learning difficulties. The assessment can also provide recommendations for treatment and support for the child and the family.
Choice D reason: This is not a helpful intervention. Consistent and firm discipline is important for any child, but it may not be enough to change the child's behavior if there are other underlying issues. Moreover, harsh or punitive discipline may worsen the child's anger and aggression. The parent should be encouraged to use positive reinforcement, empathy, and problem-solving skills with the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Suctioning the mouth and nasopharyngeal passages is the most important priority for airway care after a cleft palate repair. This is because the infant may have blood, mucus, or secretions in the mouth or nose that can obstruct the airway and cause breathing difficulties. Suctioning can help clear the airway and prevent aspiration, infection, or hypoxia.
Choice B reason: Cleaning the suture line with normal saline is an important part of wound care after a cleft palate repair, but it is not the most important priority for airway care. Cleaning the suture line can help prevent infection, promote healing, and reduce scarring. However, it should be done gently and carefully, as not to disturb the sutures or cause bleeding.
Choice C reason: Elevating the head of the bed 30 degrees is a helpful measure to facilitate breathing and drainage after a cleft palate repair, but it is not the most important priority for airway care. Elevating the head of the bed can help reduce swelling, congestion, and pressure on the surgical site. However, it should be done with caution, as not to cause neck flexion or extension that may compromise the airway.
Choice D reason: Giving IV morphine for pain is a necessary intervention to provide comfort and analgesia after a cleft palate repair, but it is not the most important priority for airway care. Giving IV morphine can help relieve the pain and distress that the infant may experience after the surgery. However, it should be given with close monitoring, as it may cause respiratory depression, sedation, or hypotension.
Correct Answer is D
Explanation
Choice A reason: This is not a correct statement, as bradycardia, bounding pulses, and cyanosis are not typical signs and symptoms of moderate congestive heart failure. Bradycardia may indicate a heart block or a vagal response, bounding pulses may indicate a patent ductus arteriosus or aortic regurgitation, and cyanosis may indicate a severe right-to-left shunt or a pulmonary embolism¹.
Choice B reason: This is not a correct statement, as overdiuresis, increased appetite, and increased thirst are not typical signs and symptoms of moderate congestive heart failure. Overdiuresis may indicate a renal dysfunction or a diuretic overdose, increased appetite may indicate a normal growth spurt or a metabolic disorder, and increased thirst may indicate dehydration or diabetes¹.
Choice C reason: This is not a correct statement, as wheezing, pallor, and capillary refill time < 2 seconds are not typical signs and symptoms of moderate congestive heart failure. Wheezing may indicate a bronchospasm or an asthma attack, pallor may indicate anemia or shock, and capillary refill time < 2 seconds may indicate a normal or increased peripheral perfusion¹.
Choice D reason: This is the correct statement, as tachypnea, cough, and tachycardia are typical signs and symptoms of moderate congestive heart failure. Tachypnea may indicate a respiratory distress or a pulmonary edema, cough may indicate a fluid accumulation or an infection in the lungs, and tachycardia may indicate a compensatory mechanism or a cardiac arrhythmia¹².
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