A home health nurse is reinforcing teaching about dietary needs with the child of a client. They state, "I don't know what to do because they're not eating." Which of the following responses should the nurse make?
"I'm sure it's nothing serious and their appetite will return soon."
"Tell me more about what happens at mealtime."
"Why do you think they're not eating?"
"They may need a feeding tube."
The Correct Answer is B
Choice A Reason:
"I'm sure it's nothing serious and their appetite will return soon." Is incorrect. This response dismisses the concern without addressing the underlying issue. It might overlook potential reasons for the lack of appetite and could lead to neglecting a serious problem.
Given the concern about the client not eating, the most appropriate response for the nurse to make would be:
Choice B Reason:
"Tell me more about what happens at mealtime." Is correct. This response encourages the child to share specific details about the mealtime routine, any challenges, or reasons behind the lack of eating. It allows the nurse to gather more information, identify potential issues, and offer appropriate guidance or interventions. Understanding the context surrounding the eating habits can help determine the best approach to address the situation effectively.
Choice C Reason:
"Why do you think they're not eating?" is incorrect. While it encourages discussion, this response puts the responsibility on the child to provide explanations that they might not fully understand or be equipped to articulate. It's essential for the nurse to gather information but in a more supportive and guiding manner.
Choice D Reason:
"They may need a feeding tube." Is incorrect. Jumping to a conclusion about a feeding tube without gathering more information or exploring other possibilities could alarm the child unnecessarily. This response could also create unnecessary worry for the child and the family without assessing the situation comprehensively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
A filter needle is used to prevent any glass particles from entering the syringe when drawing medication from an ampule, as ampules are made of glass that can sometimes break and leave shards.
Choice B Reason:
Adding 0.5 ml of diluent to the medication is incorrect. Adding diluent to medication from an ampule is not a standard practice. Ampules usually contain pre-measured doses of medication and are designed for direct withdrawal without dilution. Adding diluent could alter the concentration and effectiveness of the medication.
Choice C Reason:
The ampule should be cleansed before opening to remove any potential contaminants. Once the ampule is opened, the inside of the ampule and the medication should be considered sterile, so there is no need to cleanse the tip after opening.
Choice D Reason:
Injecting air into the ampule prior to drawing the medication into a syringe is incorrect. This action is not typically necessary when withdrawing medication from an ampule. Some medications may require air to equalize pressure, but it's crucial to follow specific guidelines for each medication. In most cases, creating positive pressure by injecting air into the ampule is not recommended, as it could affect the stability or integrity of the medication.
Correct Answer is D
Explanation
Choice A Reason:
Urinating after the specimen collection is incorrect. While it's important to ensure urine doesn't contaminate the stool specimen during collection, the instruction to urinate after the collection doesn't directly impact the collection process itself. The primary focus is on avoiding contamination of the stool sample with urine or toilet tissue during collection.
Choice B Reason:
Placing 1.3 cm (0.5 in) of formed stool into a culture tube is incorrect. The amount of stool needed for a specimen can vary based on the specific test requirements or laboratory instructions. A fixed measurement, like 1.3 cm of formed stool, might not accurately represent the necessary quantity for all types of stool tests. Specific instructions from the healthcare provider or laboratory should be followed for proper collection.
Choice C Reason:
Keeping the specimen in a warm area is incorrect. Stool specimens are typically collected and stored at room temperature unless otherwise specified by specific test instructions. Placing the specimen in a warm area could alter the characteristics of the sample or promote bacterial growth, potentially affecting test accuracy. The specimen should be handled according to the specific requirements outlined for the particular test.
Choice D Reason:
Avoid placing toilet tissue in the bedpan after defecation is correct. Placing toilet tissue in the bedpan after defecation can contaminate the stool specimen, affecting the accuracy of test results. It's important to collect the stool sample without any contamination from toilet tissue or urine.
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