The mother of a 2-month-old infant is afraid of giving her child immunizations and asks why they are necessary. The nurse's best response would be:
"If you do not immunize your child, you are putting the whole community at risk."
"Could you tell me more about your concerns regarding immunizations?"
"Your child will not be able to attend school unless he is immunized."
"Immunizations are critical to keep your child healthy."
The Correct Answer is B
Choice A reason: This is not the best response, as it may sound accusatory and judgmental. It may also increase the mother's fear and resistance to immunizations.
Choice B reason: This is the best response, as it shows empathy and respect for the mother's feelings. It also invites the mother to share her worries and doubts, which can help the nurse understand and address them.
Choice C reason: This is not the best response, as it may sound coercive and threatening. It may also imply that the only reason to immunize the child is to comply with the school requirements, not to protect his health.
Choice D reason: This is not the best response, as it may sound too general and vague. It may also not address the mother's specific concerns or questions about immunizations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Unfamiliar equipment should be shown to the child and the family before the surgery, as part of the preoperative education and preparation. This can help reduce the child's fear and anxiety, as well as increase the child's understanding and cooperation during the surgery¹.
Choice B reason: Explain that an endotracheal tube will be needed for the surgery, regardless of how well it goes. The endotracheal tube is inserted through the mouth or nose into the trachea to provide mechanical ventilation during the surgery and the immediate postoperative period. The child and the family should be informed about the purpose, duration, and possible complications of the endotracheal tube, as well as the methods of communication and comfort measures².
Choice C reason: Mention the postoperative discomfort and interventions that the child may experience after the surgery, such as pain, nausea, chest tubes, drains, dressings, and monitors. The child and the family should be reassured that these are normal and expected, and that the nurse will provide adequate pain relief and care. The child and the family should also be taught about the postoperative activities and exercises, such as deep breathing, coughing, turning, and leg movements, to promote recovery and prevent complications³.
Choice D reason: Let the child hear the sounds of an ECG monitor, as well as other equipment that will be used during the surgery, such as a blood pressure cuff, an oxygen mask, and an IV pump. This can help familiarize the child with the sounds and sensations that he or she will encounter during the surgery, and reduce the fear of the unknown. The child should also be encouraged to ask questions and express feelings about the surgery⁴.
Correct Answer is B
Explanation
Choice A reason: Cardiac arrhythmia is an abnormal heart rhythm that can affect the heart's ability to pump blood. However, it is not a direct consequence of a ventricular septal defect (VSD), which is a hole in the wall between the lower chambers of the heart¹.
Choice B reason: Decreased cardiac output is the amount of blood pumped by the heart per minute. It can be reduced by a VSD, as the blood can flow back from the left ventricle to the right ventricle through the hole, instead of being pumped to the body. This can cause the infant to have cool extremities, thready pulses, and low urine output, as the tissues are not receiving enough oxygen and nutrients².
Choice C reason: Increased stroke volume is the amount of blood pumped by the heart per beat. It can be increased by a VSD, as the left ventricle has to work harder to compensate for the blood loss through the hole. However, this does not explain the infant's symptoms, as the stroke volume may not be enough to maintain a normal cardiac output².
Choice D reason: Cyanosis is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. It can be caused by a VSD, as the oxygen-rich blood from the left ventricle can mix with the oxygen-poor blood from the right ventricle through the hole, and then be pumped to the body. However, this is more likely to occur in large VSDs or in infants with other heart defects that cause right-to-left shunting of blood³.
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