The nurse is assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

Holding head upright and sitting unsupported.

Pushing food out with their tongue.

Grasping small objects and not letting go.

The infant is between 4 and 6 months old.

Answer and Explanation

The Correct Answer is B

Choice A reason: Holding their head upright and sitting unsupported are signs that an infant may be ready for solid foods. These motor skills indicate that the baby has enough control to handle swallowing food safely.

Choice B reason: Pushing food out with their tongue is known as the tongue-thrust reflex, and it is a sign that the infant may not be ready for solid foods yet. This reflex prevents choking and generally diminishes between 4 and 6 months of age.

Choice C reason: Grasping small objects and not letting go demonstrates that the baby has developed fine motor skills, which are also important for starting solid foods. However, this alone does not determine readiness.

Choice D reason: Being between 4 and 6 months old is an appropriate age range for introducing solid foods, as long as other readiness signs are also present. Age alone is not the sole indicator of readiness for solid foods.

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Correct Answer is D

Explanation

Choice A reason: Having the caregivers in the room with the patient may not provide a confidential and comfortable environment for the 16-year-old. Adolescents may feel embarrassed or reluctant to discuss sensitive issues related to sexually transmitted infections (STIs) in front of their caregivers. This approach does not fully support patient-cantered care, which focuses on respecting the patient’s privacy and promoting open communication.

Choice B reason: Providing written reading materials is an important aspect of education, but it may not be sufficient on its own to ensure that the patient fully understands the information. Reading materials should be supplemented with personalized discussion to address specific concerns and questions the patient may have. Therefore, while helpful, this intervention alone does not represent the most patient-cantered approach.

Choice C reason: Educating the patient to avoid sexual activity is a limited approach that does not consider the complexities of an adolescent's experiences and needs. A more patient-cantered approach would involve discussing safe sexual practices, STI prevention methods, and empowering the patient with comprehensive information to make informed decisions about their sexual health, rather than simply advising abstinence.

Choice D reason: Assessing the patient alone provides a private and supportive environment where the 16-year-old can feel more comfortable discussing sensitive topics. This approach respects the patient’s autonomy, ensures confidentiality, and allows for more open and honest communication. It demonstrates a commitment to patient-cantered care by addressing the individual needs and concerns of the patient.

A. Children may become anxious when they have to be in a health care setting. B. Children with ASD are at greater risk for experiencing anxiety. C. Children with ASD have mood disorders. D. Worrying is normal for this age group.

Correct Answer is B

Explanation

Choice A reason: While it is true that children may become anxious when they have to be in a health care setting, this statement does not specifically address the unique situation of a child with atrial septal defect (ASD). The diagnosis of ASD can contribute to an increased risk of anxiety due to the underlying health condition and its implications, rather than just the health care setting alone.

Choice B reason: Children with atrial septal defect (ASD) are indeed at a greater risk for experiencing anxiety. The presence of a congenital heart condition can create significant stress and worry for the child and their family. The anxiety could stem from concerns about their health, potential treatments, and the impact of the condition on their daily life. Therefore, this response appropriately acknowledges the connection between the diagnosis of ASD and the increased anxiety levels observed in the child.

Choice C reason: Although children with atrial septal defect may experience anxiety, the statement that children with ASD have mood disorders is not necessarily accurate. Mood disorders and anxiety are distinct conditions, and while they can co-occur, it is not a given that a child with ASD will have mood disorders. Thus, this response is not entirely appropriate for addressing the caregivers' concern.

Choice D reason: Worrying can be considered normal for children in general; however, this response does not specifically address the context of the child's atrial septal defect (ASD) and its potential impact on their anxiety levels. This statement is too generalized and does not provide the caregivers with the necessary reassurance and information related to the diagnosis of ASD. Therefore, it is not the most appropriate response from the nurse.

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The nurse is assessing a 5-month-old patient on their readiness for solid foods. Which observation will indicate the family should postpone solid foods?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing sexually transmitted infection education to a 16-year-old. What nursing intervention demonstrates patient-cantered care?

Correct Answer is D

Explanation

The nurse is caring for a 13-year-old diagnosed with atrial septal defect (ASD). Their caregivers report that the child seems more anxious and worried than usual. Considering the diagnosis of ASD, which of the following responses is appropriate for the nurse to make?

Correct Answer is B

Explanation

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