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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."

Answer and Explanation

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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Correct Answer is B

Explanation

A. An electrical source. Electrical burns often cause deep tissue damage that may not be visible on the surface. These burns can extend beyond the skin, affecting muscles, nerves, and internal organs, making them more severe than partial-thickness burns.

B. Contact with hot liquid. Scald burns from hot liquids (e.g., boiling water, coffee, soup) are a common cause of partial-thickness burns. These burns affect the epidermis and part of the dermis, leading to blistering, redness, and pain.

C. A mild sunburn. Mild sunburns typically cause superficial burns (first-degree burns), affecting only the epidermis and resulting in redness and discomfort without blisters. Partial-thickness burns involve deeper skin layers.

D. Contact with a flame. Direct contact with a flame is more likely to cause deeper burns, often resulting in full-thickness burns (third-degree) rather than partial-thickness burns.

A. Mood changes B. Swollen knees C. Frequent falls D. Dental caries

Correct Answer is B

Explanation

A. Mood changes. While mood changes can occur due to various health conditions, they are not a direct indicator of a bleeding disorder. Bleeding disorders typically present with physical symptoms like easy bruising or joint swelling.

B. Swollen knees. Joint swelling (hemarthrosis) is a key sign of bleeding disorders such as hemophilia. In children with a bleeding disorder, even minor trauma can cause bleeding into the joints, leading to pain, stiffness, and swelling, particularly in weight-bearing joints like the knees and ankles.

C. Frequent falls. While frequent falls may result in bruising, they are not a direct indicator of a bleeding disorder. However, children with a bleeding disorder may bruise excessively or experience prolonged bleeding after minor falls.

D. Dental caries. Dental caries (tooth decay) is not a symptom of a bleeding disorder but rather results from poor oral hygiene, dietary factors, or bacterial infection. Bleeding disorders may cause prolonged bleeding after dental procedures, but they do not directly cause cavities.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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