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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. "You must breastfeed to give the baby the best nutrients." While breastfeeding provides essential nutrients, it is not recommended for mothers with HIV due to the risk of viral transmission through breast milk, even if the mother is on antiretroviral therapy.

B. "Breastfeeding is not recommended because of the high risk of transmission." HIV can be transmitted through breast milk, and health organizations, including the WHO and CDC, advise against breastfeeding if safe alternatives, such as formula feeding, are available. Formula feeding is the preferred method in high-resource settings.

C. "Pumped breastmilk may be given to your child." Pumping does not eliminate HIV from breast milk. The virus remains present, posing the same transmission risk as direct breastfeeding.

D. "You should sterilize your pumped breastmilk prior to feeding." There is no reliable method for sterilizing breast milk at home that effectively eliminates HIV without destroying its nutritional value. Instead, formula feeding or donor milk from screened sources is recommended.

A. “Cognitive abilities in children with Down syndrome cannot be improved, so focusing on physical health is the only priority." B. “Infants who have Down syndrome typically have significantly higher IQ scores compared to typically developing infants." C. “Early intervention programs can mitigate cognitive impairments in infants who have Down syndrome." D. “Cognitive abilities of infants who have Down syndrome are typically within the average range during the first year of life."

Correct Answer is C

Explanation

A. "Cognitive abilities in children with Down syndrome cannot be improved, so focusing on physical health is the only priority." While children with Down syndrome do experience cognitive impairments, early intervention programs such as speech, occupational, and physical therapy can enhance cognitive, motor, and social development, improving their overall functioning.

B. "Infants who have Down syndrome typically have significantly higher IQ scores compared to typically developing infants." Children with Down syndrome generally have mild to moderate intellectual disability, and their IQ scores tend to be lower than typically developing peers, not higher.

C. "Early intervention programs can mitigate cognitive impairments in infants who have Down syndrome." This is correct. Early stimulation, structured learning environments, and specialized therapies can help optimize the child's cognitive potential and improve adaptive skills.

D. "Cognitive abilities of infants who have Down syndrome are typically within the average range during the first year of life." Although some developmental milestones may appear similar in early infancy, delays in cognitive and motor development often become noticeable within the first year, distinguishing children with Down syndrome from their typically developing peers.

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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

A nurse is reinforcing education about nutrition for a patient who has HIV and has a newborn. Which of the following statements should the nurse provide in the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching to the parents of a 2-month-old infant who has Down Syndrome. Which of the following statements addressing cognitive ability should the nurse reinforce?

Correct Answer is C

Explanation

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