A patient with a severe head injury assumes a posture of flexed arms at the elbows and extended lower legs. The nurse recognizes this posturing as

Choice A reason: "You need to bring your child to the emergency department immediately and have the stool tested for blood." is not an appropriate response by the nurse. Black stools can be a sign of gastrointestinal bleeding, which is a serious condition that requires immediate medical attention. However, in this case, the black stools are most likely caused by the iron supplement, which can change the color and consistency of the stool. Therefore, there is no need to panic or rush to the emergency department.

Choice B reason: "Greenish black stools are normal when oral iron supplements are being administered." is the most appropriate response by the nurse. It is a factual and reassuring statement that explains the reason for the stool color change and educates the mother about the expected side effect of the iron supplement. It also encourages the mother to continue the treatment for the child's anemia.

Choice C reason: "You should stop administering the daily iron supplement." is not an appropriate response by the nurse. It is a harmful and incorrect advice that contradicts the prescribed treatment for the child's anemia. Stopping the iron supplement can worsen the child's condition and lead to complications such as growth retardation, cognitive impairment, or heart failure.

Choice D reason: "Don't worry about it." is not an appropriate response by the nurse. It is a dismissive and vague statement that does not address the mother's concern or provide any information or education. It can also undermine the mother's trust and confidence in the nurse and the health care system.

Choice A reason: Encouraging intake of favorite foods to increase weight and promote normal growth is an important nursing goal for a child with leukemia, but it is not the priority. Chemotherapy can cause nausea, vomiting, and loss of appetite, which can affect the child's nutritional status and growth. However, these effects can be managed with antiemetics, supplements, and small frequent meals.

Choice B reason: Utilizing approaches to minimize risk of infection and bleeding episodes is the priority nursing goal for a child with leukemia. Chemotherapy can cause bone marrow suppression, which reduces the production of white blood cells, red blood cells, and platelets. This increases the risk of infection, anemia, and bleeding, which can be life-threatening. Therefore, the nurse should monitor the child's blood counts, vital signs, and signs of infection or bleeding, and implement preventive measures such as hand hygiene, isolation, and transfusions.

Choice C reason: Providing age-appropriate activities to promote optimum cognitive and motor skills development is an important nursing goal for a child with leukemia, but it is not the priority. Chemotherapy can cause fatigue, weakness, and neuropathy, which can affect the child's physical and mental abilities. However, these effects can be managed with rest, pain relief, and stimulation.

Choice D reason: Providing emotional support for the child and family members that relieve stress is an important nursing goal for a child with leukemia, but it is not the priority. Chemotherapy can cause anxiety, depression, and fear, which can affect the child's psychological and emotional well-being. However, these effects can be managed with counseling, education, and coping strategies.