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 C
Explanation
Choice AReason:
Encouraging the client to abstain from distracting activities is incorrect. Engaging in distracting activities can actually be beneficial in pain management. It can redirect the client's focus away from the pain, potentially reducing its intensity.
Choice BReason:
Ensuring that the client's room is kept at a cool temperature is incorrect.
While temperature can influence comfort, maintaining a cool room might not directly address or alleviate the client's pain.
Choice C Reason:
Playing music in the client's room is correct. Music therapy is a nonpharmacological intervention that can effectively help in managing pain. Calming or soothing music can distract the client from pain, reduce anxiety, and promote relaxation, potentially reducing the perception of pain.
Choice D Reason:
Keep the client's room well-lit is incorrect. The lighting in the room might not significantly impact pain levels. Some individuals might prefer dim lighting for relaxation, but it might not directly influence pain perception.
Correct Answer is D
Explanation
Choice A Reason:
Adhesive tape is incorrect. Adhesive tape is commonly used for securing dressings or medical devices, but it may not be the primary supply needed for managing a stage 4 pressure injury. Wound care for a stage 4 pressure injury often involves specialized dressings, cleansing solutions, and applicators rather than adhesive tape alone.
Choice B Reason:
Tongue depressor is incorrect. A tongue depressor is typically used for oral examinations or to apply topical treatments to the mouth. It's not a standard supply for managing a stage 4 pressure injury, which requires specific wound care supplies designed for wound cleaning and dressing application.
Choice C Reason:
Syringe is incorrect. While syringes are versatile tools used in various medical procedures, in the context of managing a stage 4 pressure injury, their primary use might be for administering medications or irrigation solutions rather than being the essential supply for wound care in this specific instance.
For a client with a stage 4 pressure injury, the nurse should obtain supplies that are suitable for wound care. Among the options provided, the most appropriate supply is:
Choice D Reason:
Cotton-tipped applicator is correct. A cotton-tipped applicator can be used for wound cleaning and dressing application for a stage 4 pressure injury. It allows for gentle cleaning of the wound and application of topical treatments while minimizing trauma to the wound area.
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