The mother of a 4-year-old boy tells the nurse that her son occasionally wets his pants during the day. How should the nurse respond?
"Tell me about the circumstances when this occurs."
"Is there a family history of diabetes?"
"Suddenly having accidents can be a sign of diabetes."
"That's normal: don't worry about it."
The Correct Answer is A
A. "Tell me about the circumstances when this occurs.": This response allows the nurse to gather more information about the child's toileting habits and potential triggers for the accidents.
Understanding the context can help identify possible underlying causes and guide appropriate interventions.
B. "Is there a family history of diabetes?": While diabetes can be a cause of increased urination, asking about a family history of diabetes is premature and may unnecessarily alarm the parent before further assessment.
C. "Suddenly having accidents can be a sign of diabetes.": Jumping to conclusions about a serious medical condition like diabetes without further assessment or evidence can cause unnecessary anxiety for the parent. It's important to gather more information and consider other potential causes before suggesting a diagnosis.
D. "That's normal: don't worry about it.": While occasional daytime wetting accidents can be common in young children, dismissing the concern without further assessment may overlook potential underlying issues that could benefit from intervention or support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An anxiety reaction: The toddler's behavior of sitting quietly, sucking her thumb, and turning away from the nurse when approached after her mother leaves the room suggests anxiety. These
behaviors are common signs of distress or discomfort in young children, especially when separated from their primary attachment figure (in this case, the mother).
B. Regression: Regression involves reverting to earlier, more immature behaviors in response to stress or discomfort. While thumb sucking can be considered a form of regression, the behavior observed in this scenario is more indicative of anxiety rather than a broader regression in
developmental milestones.
C. Resentment toward the mother: There is no evidence in the scenario to suggest that the toddler is expressing resentment toward the mother. The behaviors observed are more likely related to
the child's emotional response to separation and hospitalization.
D. Developing autonomy: Developing autonomy typically involves asserting independence and exploring one's environment. The behaviors observed in the scenario are more indicative of anxiety and distress rather than autonomous behavior.
Correct Answer is A
Explanation
A. An infant's rate is 90 bpm.
An infant's normal heart rate typically ranges from 70 to 150
B. A toddler's rate is 150 bpm.
The normal heart rate for a toddler usually ranges from 70 to 130. Therefore a rate of 150 bpm would be considered tachycardia in a toddler.
C. A preschooler's rate is 130 bpm.
The normal heart rate for a preschooler typically ranges from 80 to 120 bpm, with an average rate around 100-110 bpm. A rate of 130 bpm would be considered tachycardia in a preschooler.
D. A school-age child's rate is 50 bpm.
The normal heart rate for a school-age child usually ranges from 75 to 118 bpm. A rate of 50 bpm would be considered bradycardia in a school-age child.
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