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?
Children may become anxious when they have to be in a health care setting.
Children with ASD are at greater risk for experiencing anxiety.
Children with ASD have mood disorders.
Worrying is normal for this age group.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A reason: Discontinuing the indwelling catheter is not appropriate without first assessing the cause of the low urine output.
Choice B reason: Increasing the intravenous fluid rate might be considered if the patient is dehydrated, but first, the nurse should ensure that the low urine output is not due to a mechanical issue with the catheter.
Choice C reason: Checking the catheter for patency is the most immediate and appropriate action. There could be a blockage or kink in the catheter, which might explain the low urine output.
Choice D reason: Documenting the finding is important, but it should be done after addressing the immediate concern of low urine output and confirming that the catheter is functioning properly.
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