Page 596 - Saunders Comprehensive Review For NCLEX-RN

and white, provide visual stimulation. Crying is an infant’s way of communicating;
therefore, the nurse would respond to the infant’s crying. The mother is taught to do
so also. An infant or child should never be allowed to fall asleep with a bottle
containing milk, juice, soda pop, sweetened water, or another sweet liquid because
of the risk of nursing (bottle-mouth) caries.
Test-Taking Strategy: Focus on the subject, care of the infant. Noting the word
loud and the words at least 10 minutes before responding will assist in eliminating these
interventions. Also, recalling the concerns related to dental caries will assist in
eliminating option 3.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process—Implementation
Content Area: Developmental Stages: Infant
Health Problem: N/A
Priority Concepts: Development; Safety
Reference: Hockenberry, Wilson, Rodgers (2017), pp. 60-61.

169. Answer: 3, 5, 6

Rationale: The nurse must determine whether there is a spokesperson for the
family and how much the client and family want to know. The nurse needs to allow
the family and client the opportunity for informed choices and assist with the
decision-making process if asked. The nurse should encourage expression of
feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let
the client and family know they will not be abandoned. The nurse should touch and
hold the client’s or family member’s hand, if appropriate.
Test-Taking Strategy: Use therapeutic communication techniques and recall
client and family rights to assist in directing you to the correct options.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Developmental Stages: End-of-Life Care
Health Problem: N/A
Priority Concepts: Family Dynamics; Palliation
Reference: Potter et al. (2017), pp. 761-762.

170. Answer: 4

Rationale: On occasion, tenderness, redness, or swelling may occur at the site of
the DTaP injection. This can be relieved with cold packs for the first 24 hours,
followed by warm or cold compresses if the inflammation persists. Bringing the
infant back to the clinic is unnecessary. Option 1 may be an appropriate intervention
but is not specific to the subject of the question, a localized reaction at the injection
site. Hot packs are not applied and can be harmful by causing burning of the skin.
Test-Taking Strategy: Focus on the subject, a localized reaction at the injection
site. Option 1 can be eliminated first because it does not relate specifically to the
subject of the question. Eliminate option 2 next as an unnecessary intervention. From

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