A home health nurse is collecting data on an adolescent who has cystic fibrosis. The child expresses concern about experiencing increasing episodes of respiratory distress and asks the nurse for insight into the possible reasons. Which of the following responses should the nurse make?
"As a nurse, I can't diagnose what is causing you to have worsening symptoms. However, I will relay this information to your healthcare provider so they can determine what should happen next."
“If you are experiencing worsening respiratory distress, we must get you to the emergency department immediately.”
“It sounds like you may be concerned that your condition could be getting worse. That can be scary tell me more about what you have been experiencing."
"As you know, cystic fibrosis is a respiratory disease. Increased respiratory distress is a characteristic symptom of this disorder."
The Correct Answer is C
A. "As a nurse, I can't diagnose what is causing you to have worsening symptoms. However, we will relay this information to your healthcare provider so they can determine what should happen next." While it is true that nurses cannot diagnose, this response does not address the adolescent’s concerns or encourage them to share more information about their symptoms.
B. "If you are experiencing worsening respiratory distress, we must get you to the emergency department immediately." This response may create unnecessary alarm without first assessing the severity of the symptoms. While severe distress requires urgent care, the nurse should first gather more information.
C. "It sounds like you may be concerned that your condition could be getting worse. That can be scary—tell me more about what you have been experiencing." This is correct because it acknowledges the adolescent's emotions, encourages open communication, and allows the nurse to gather more information before determining the appropriate course of action.
D. "As you know, cystic fibrosis is a respiratory disease. Increased respiratory distress is a characteristic symptom of this disorder." While this statement is factually correct, it dismisses the adolescent’s concern instead of providing reassurance, emotional support, and further assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Cardiac enzymes. Cardiac enzyme tests are used to assess heart damage, such as in myocardial infarction, and are not typically relevant in evaluating a child's nutritional status.
B. Complete blood count. A CBC is a key diagnostic test for assessing nutritional status, as it can reveal anemia (low hemoglobin and hematocrit), infection (elevated white blood cells), and overall health status. It helps identify deficiencies in iron, folate, and vitamin B12, which are common nutritional concerns in children.
C. Blood coagulation tests. Coagulation tests (e.g., PT, INR, aPTT) are used to assess blood clotting disorders and monitor anticoagulant therapy, but they are not standard tests for nutritional assessment unless there is suspicion of a vitamin K deficiency.
D. Arterial blood gases. ABG tests assess respiratory function and acid-base balance, which are more relevant in critically ill patients. They are not routinely used to evaluate a child's nutritional status.
Correct Answer is B
Explanation
A. "Palliative care should be given separately from curative care." Palliative care can be provided alongside curative treatments to enhance comfort and quality of life. It is not limited to end-of-life care but focuses on symptom management and emotional support throughout the illness.
B. "Clinicians should participate in the discussion with the family about the child's prognosis." Open, honest, and compassionate communication between healthcare providers and families is crucial. Clinicians help families understand the prognosis, treatment options, and goals of care, ensuring informed decision-making.
C. "Parents who express hope of their child surviving are less accepting of palliative care." Parents can hope for a cure while still accepting palliative care to improve their child's comfort and quality of life. Hope and palliative care are not mutually exclusive.
D. "Palliative care should be offered once a child has less than 6 months to live." Palliative care is not limited to a specific timeframe. It can begin at diagnosis of a serious illness and continue throughout treatment, rather than being restricted to end-of-life care.
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