A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?
"Haven't you been feeding according to recommended daily allowances for children?"
"Does your child seem mentally slower than his peers also?"
"You should not worry about the growth tables. They are only averages for children."
"The smaller size is probably due to the heart disease."
The Correct Answer is D
A. "Haven't you been feeding according to recommended daily allowances for children?": This response implies blame and lacks sensitivity. It doesn't acknowledge the child’s underlying medical condition that may affect growth.
B. "Does your child seem mentally slower than his peers also?": Intellectual development is unrelated to height/weight percentile in children with congenital heart disease unless there are neurological complications, which haven't been indicated.
C. "You should not worry about the growth tables. They are only averages for children.": While growth charts are averages, they are clinically significant, especially for identifying underdevelopment in children with chronic illnesses.
D. "The smaller size is probably due to the heart disease.": Chronic hypoxia and increased metabolic demands in congenital heart disease often contribute to poor weight gain and growth delay, making this the most informative and empathetic response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
Correct Answer is A
Explanation
A. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: Discarding the first void ensures the collection begins with an empty bladder, and all urine afterward is included for accurate measurement.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours, for the next 24 hours: This describes timed urine sampling, not a continuous 24-hour collection required for creatinine clearance.
C. For the next 24 hours, notify nurse when the bladder is full, and the nurse will collect catheterized specimens: Routine creatinine clearance testing does not require catheterization unless the client is already catheterized.
D. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle: This describes a midstream or clean-catch technique, typically used for urine cultures, not 24-hour collections.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
