a nurse is caring for an 8 month old infant who screams when the parent leaves the room the parent begins to cry and says i dont understand why my chi
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Nursing Elites

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ATI Nutrition

1. A nurse is caring for an 8-month-old infant who screams when the parent leaves the room. The parent begins to cry and says, 'I don't understand why my child is so upset. I've never seen my child act this way around others before.' Which of the following statements should the nurse make?

Correct answer: A

Rationale: The correct answer is 'This is a normal, expected reaction for a child of this age.' Separation anxiety typically peaks around 8-10 months of age, leading to distress when separated from caregivers. Choice B is incorrect because the infant's behavior is more likely due to separation anxiety rather than overstimulation. Choice C is incorrect as the infant's behavior is not related to overexposure to caregivers but rather a natural developmental stage. Choice D is incorrect as the infant's behavior is not indicative of illness but rather a normal emotional response.

2. A patient tells the nurse “I am depressed to talk to you, leave me alone” Which of the following response by the nurse is most therapeutic?

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. Patients maintained using peritoneal dialysis may gain weight because:

Correct answer: C

Rationale: Glucose from the peritoneal dialysis solution can be absorbed into the bloodstream, leading to weight gain if not balanced with diet and activity.

4. A nurse is instructing the mother of a toddler who has iron-deficiency anemia to increase iron in the child's diet in addition to the prescribed iron supplement. Which of the following foods should the nurse recommend?

Correct answer: C

Rationale: Tuna fish is a good source of iron and would be beneficial for a toddler with iron-deficiency anemia. Skim milk, bananas, and cucumbers are not significant sources of iron and would not help in increasing the iron levels in the child's diet. Skim milk, in particular, can inhibit iron absorption due to its calcium content, which is important for the nurse to educate the mother about.

5. A client receiving total parenteral nutrition (TPN) suddenly develops tremors, dizziness, and diaphoresis. The client said, 'I feel weak and the bag was empty.' Which is the most likely complication the client is currently experiencing?

Correct answer: D

Rationale: The client experiencing tremors, dizziness, diaphoresis, weakness, and stating that the TPN bag is empty is likely experiencing hypoglycemia. Hypoglycemia can occur when the TPN infusion suddenly stops, leading to a rapid drop in blood sugar levels. Symptoms of hypoglycemia include tremors, dizziness, diaphoresis, and weakness. Choices A, B, and C are incorrect as the symptoms presented are more consistent with hypoglycemia rather than fluid volume overload, sepsis, or hyperglycemia.

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