Parents tell the nurse that their two-year-old son often sleeps with them. They seem unconcerned about this. The nurse's response should be based on which of the following?
Daytime attention should be increased.
This is a common practice, especially in some cultural groups.
It is illegal for parents to sleep with their children, and this is reportable abuse.
Separation from parents should be completed by this age.
The Correct Answer is B
Choice A reason: This is not a valid basis for the nurse's response, as it implies that the child sleeps with the parents because of a lack of attention during the day. This may not be the case, and it may also offend the parents by questioning their parenting skills.
Choice B reason: This is a valid basis for the nurse's response, as it acknowledges the diversity and variability of family practices and preferences. It also shows respect and sensitivity for the parents' and the child's needs and comfort.
Choice C reason: This is not a valid basis for the nurse's response, as it is false and exaggerated. Sleeping with one's children is not illegal or abusive, unless there is evidence of harm or neglect. It may also alarm and anger the parents by accusing them of a crime.
Choice D reason: This is not a valid basis for the nurse's response, as it is based on a rigid and arbitrary developmental milestone. There is no fixed age for separating from parents, and it may vary depending on the child's temperament, attachment, and environment. It may also pressure and guilt the parents by implying that they are delaying their child's growth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This response is not the priority action because dehydration is not an immediate threat to the child's life. The nurse should first rule out any signs of hemorrhage, which is a common complication of tonsillectomy.
Choice B reason: This response is not the priority action because pain medication may mask the symptoms of bleeding, such as increased swallowing or restlessness. The nurse should first assess the child for any signs of hemorrhage, and then administer pain medication as needed.
Choice C reason: This response is not the priority action because cherry popsicles may irritate the throat and cause bleeding. The nurse should first assess the child for any signs of hemorrhage, and then offer clear fluids or ice chips to the child.
Choice D reason: This response is the priority action because post-op bleeding is a serious and potentially fatal complication of tonsillectomy. The nurse should assess the operative site for any signs of bleeding, such as fresh blood, clots, or increased swallowing. The nurse should also monitor the child's vital signs, oxygen saturation, and level of consciousness. If bleeding is suspected, the nurse should notify the physician immediately and prepare for emergency interventions.
Correct Answer is D
Explanation
Choice A reason: A consistent growth pattern on the 25th percentile is not an indicator of child abuse. It means that the child is growing normally and is within the expected range for their age and gender.
Choice B reason: A contusion on the child's leg is not necessarily an indicator of child abuse. It could be a result of accidental injury or normal play. However, the nurse should assess the location, size, shape, and color of the bruise, and compare it with the parents' explanation.
Choice C reason: Fearful behavior when the nurse enters the room is not a specific indicator of child abuse. It could be a sign of anxiety, shyness, or discomfort in an unfamiliar setting. The nurse should try to establish rapport with the child and use developmentally appropriate communication techniques.
Choice D reason: An inconsistent story on the child's injury is a strong indicator of child abuse. It suggests that the parents are trying to hide or cover up the cause of the injury, or that they are not aware of how the injury occurred. The nurse should document the discrepancies and report any suspicions of abuse to the appropriate authorities.
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