A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

The child has red fissures at the corners of the mouth.

The child has several small bruises on both legs.

The child sleeps for about 13 hours each night.

The child is not regularly attending school.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Reminding the staff members that viewing the electronic medical record of a celebrity client without proper authorization is a breach of confidentiality is the immediate action required in this situation. It addresses the ethical and legal concerns related to patient privacy and ensures that the staff members are reminded of their professional responsibilities.

Choice B rationale:

Discussing the issue with the nurse manager is a step that can be taken after addressing the immediate breach of confidentiality. While involving the manager is important for handling the situation more comprehensively, the first priority is to stop the unauthorized access.

Choice C rationale:

Requesting an administrative restriction on the client's record access is an option that can be considered, but it may not be the first step to take. Before implementing such a restriction, the breach of confidentiality should be addressed directly with the staff members involved.

Choice D rationale:

Preparing a memo for the facility ethics committee is not the initial action to take in response to the breach of confidentiality. This step might be appropriate for addressing systemic issues or policy changes related to confidentiality breaches, but it doesn't directly address the immediate situation at hand.

A. Interpreter. B. Social worker. C. Occupational therapist. D. Spiritual advisor.

Correct Answer is A

Explanation

Choice A rationale:

Since the client speaks a different language than the nurse, involving an interpreter is crucial to ensure effective communication during the preoperative teaching. This will help the client fully understand the procedure, potential risks, and postoperative care instructions.

Choice B rationale:

A social worker primarily addresses psychosocial needs and resources. While they play an important role, their involvement wouldn't directly address the language barrier during the preoperative teaching.

Choice C rationale:

An occupational therapist assists with physical function and daily activities. While they might be involved postoperatively, their role is not as crucial for overcoming the language barrier during preoperative teaching.

Choice D rationale:

A spiritual advisor provides support based on religious or spiritual beliefs. While emotional and spiritual support are important, their involvement in this scenario doesn't address the language barrier and the need for accurate information during preoperative teaching.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse walks into the nurses' station and sees several staff members looking at the electronic medical record for a celebrity client on another unit. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is providing preoperative teaching for a client who is scheduled for a total knee arthroplasty and speaks a different language than the nurse. Which of the following interprofessional team members should the nurse include in the discussion?

Correct Answer is A

Explanation

A nurse manager needs to address an increased rate of client medication errors. Which of the following strategies represents an authoritarian approach to managing this issue?

A client is considering having a tubal ligation and reports being uncertain about if it is the right thing to do. Which of the following actions should the nurse take?

A client who has back pain presents to an emergency department and is provided a prescription for oxycodone. A staff nurse tells the charge nurse that they think the client is seeking drugs and is not actually in distress. Which of the following responses should the charge nurse make?

A nurse is caring for a client who has a terminal illness and voices concern about performing self-care after discharge. Which of the following statements should the nurse make?

A nurse on a quality improvement team is implementing a plan to decrease the rate of pressure injuries in a long-term care facility. Which of the following actions should the team take to evaluate the effectiveness of the plan?

A nurse manager is planning an in-service for a group of nurses about caring for clients following stem cell transplants. Which of the following instructions should the nurse manager include in the teaching?

A nursing unit is undergoing changes to accommodate new bariatric services that will be available on the unit. Some staff members have verbalized displeasure with the changes. Which of the following actions should the charge nurse take?

A nurse is caring for a client who is recovering from a stroke. The provider recommends an extracranial-intracranial bypass, but the client tells the nurse that he will not have the surgery. Which of the following actions should the nurse take?