A nurse cares for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?
"This is a typical reaction for a child who is sick."
"This is a response to an overstimulating environment."
"This is a normal, expected reaction for a child of this age."
"This is a common reaction to an overexposure to caregivers."
The Correct Answer is C
A. "This is a typical reaction for a child who is sick.” While illness may heighten distress, the behavior described—crying when the parent leaves—is more related to developmental stage than to acute illness, and should not be solely attributed to sickness.
B. "This is a response to an overstimulating environment." Overstimulation can cause fussiness or irritability, but separation anxiety, not overstimulation, best explains the infant’s reaction to the parent leaving.
C. "This is a normal, expected reaction for a child of this age." Separation anxiety typically emerges around 6–8 months of age as infants begin to understand object permanence. The child’s distress upon separation is a developmentally appropriate behavior.
D. "This is a common reaction to an overexposure to caregivers." Overexposure does not lead to distress when a caregiver leaves. Rather, strong attachment bonds cause infants to become upset when their primary caregiver is not present.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Calculation:
Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 88 lb / 2.2 lb/kg
= 40 kg
Calculate the desired dose per administration in milligrams (mg).
Desired dose per administration (mg) = Desired dose (mg/kg) × Weight (kg)
= 5 mg/kg × 40 kg
Correct Answer is A
Explanation
A. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing: This significant drop in blood pressure upon standing indicates orthostatic hypotension, which can be an early sign of hypovolemia or autonomic instability. It requires immediate evaluation to prevent complications like syncope or shock.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation: A mild to moderate increase in pain after activity is expected in injuries. While it should be monitored, it does not require immediate provider notification unless unrelieved by interventions or accompanied by neurovascular changes.
C. A client who has a burn injury to an estimated 5% of his leg and is crying: Crying in response to a burn injury reflects pain or emotional distress but is not an urgent clinical concern with only 5% total body surface area involvement. Pain should be managed, but the situation is not immediately life-threatening.
D. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F): This temperature is within the normal postoperative range and can reflect the body's inflammatory response to surgery. It does not indicate infection or a critical issue that needs immediate reporting.
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