A nurse, who is caring for a chronically ill 6-year-old child in a long-term care facility, has identified
the following nursing diagnosis for the child: Ineffective Coping as evidenced by detachment
behaviors. When the child’s parents left the hospital after a visit, which of the following assessments did
the nurse observe? The child:
cried and begged the parents to stay.
waved good bye and asked the parents when they would return.
The Correct Answer is C
A chronically ill child demonstrating detachment behaviors may appear indifferent to the parents, show minimal distress upon separation, or redirect attachment to caregivers such as nurses. This behavior reflects ineffective coping, often seen when the child has experienced prolonged hospitalizations or repeated separations from parents.
Rationale for correct answer:
C. Hugging the nurse and ignoring the parents indicates detachment. Instead of showing distress or seeking comfort from parents, the child transfers attachment to the nurse and minimizes interaction with the parents. This is a maladaptive coping response to prolonged separation and hospitalization.
Rationale for incorrect answers:
A. Crying and begging the parents to stay represents separation anxiety, not detachment. It reflects active emotional attachment and protest.
B. Waving good bye and asking the parents when they would return is a healthy coping behavior, showing trust and security in the parents’ return. It is not detachment.
D. Grabbing the legs of the parents and refusing to let them go reflects protest behavior, not detachment. The child is still strongly attached and resists separation.
Take home points
- Detachment behaviors occur when a child adapts to repeated separation by withdrawing emotional connection from parents and attaching to others.
- This indicates ineffective coping and requires interventions to support parent-child bonding.
- Nurses should encourage frequent parental involvement and provide opportunities for positive interactions.
- Distinguishing between protest, despair, and detachment phases of separation anxiety is key in pediatric nursing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for culturally diverse families, the nurse’s priority is to understand the parents’ perception of the illness or disability. This approach acknowledges their beliefs, values, and concerns, allowing the nurse to provide culturally sensitive care while building trust.
Rationale for correct answer:
C. By exploring the parents’ perceptions, concerns, and worries, the nurse gains insight into how the family views the illness, its seriousness, and how they believe it should be managed. This facilitates individualized, culturally competent care and promotes collaboration.
Rationale for incorrect answers:
A. Asking about the extended family’s views may provide some information, but it does not directly address the parents’ own beliefs and perceptions, which are essential for guiding care.
B. Exploring alternative therapies is important but comes after understanding the family’s overall view of the illness. It is one aspect of cultural care, not the starting point.
D. Acknowledging language barriers is necessary, but it does not justify health care professionals making decisions without family input. Professional interpreters should be used to ensure communication and respect for family values.
Take home points
- The first step is to understand the family’s own perception of the illness/disability.
- Cultural competence means listening, respecting, and integrating beliefs into care when safe and possible.
- Extended family input and alternative therapies can be explored after building understanding.
- Use interpreters, not assumptions, to overcome language barriers and support shared decision-making.
Correct Answer is ["B","D"]
Explanation
Down syndrome is a genetic condition caused by the presence of an extra copy of chromosome 21, which is why it's also called trisomy 2A. This additional genetic material affects how the body and brain develop, leading to a range of physical, cognitive, and developmental differences.
Rationale for correct answers:
B. Protruding tongue is common in infants with Down syndrome, often due to hypotonia and a relatively small oral cavity.
D. Wide, flat nasal bridge is a typical facial characteristic of Down syndrome, helping distinguish craniofacial appearance in affected infants.
Rationale for incorrect answers:
A. Elongated face is not characteristic of Down syndrome. It is more commonly seen in conditions like Marfan syndrome.
C. Infants with Down syndrome typically have small, low-set ears, not large or high-set.
E. Asymmetric Moro reflex usually suggests birth injury such as brachial plexus injury or clavicle fracture rather than Down syndrome.
Take home points
- Classic Down syndrome features in newborns include: hypotonia, protruding tongue, wide flat nasal bridge, small ears, simian crease, and upslanting palpebral fissures.
- Differentiating features are important because other syndromes (e.g., trisomy 13 or 18, Marfan syndrome) have distinct facial/physical characteristics.
- Early recognition allows timely screening for associated conditions such as congenital heart disease, GI anomalies, and thyroid dysfunction.
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