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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer is: Wear an N95 respirator mask when in the client’s room.
Explanation: Pulmonary tuberculosis (TB) is a contagious disease caused by bacteria that can spread through the air. The most common way of transmission is through respiratory droplets that are expelled when a person with active TB coughs, sneezes, or speaks1. Therefore, the charge nurse should expect the newly licensed nurse to take precautions to protect themselves and the client from exposure to TB. One of these precautions is to wear an N95 respirator mask when in the client’s room2. An N95 respirator mask is a type of personal protective equipment (PPE) that filters out at least 95% of airborne particles, including bacteria and viruses3. It can prevent the nurse from inhaling or spreading TB to others.
The other options are incorrect because:
Place the client on droplet precautions: Droplet precautions are not enough to prevent transmission of TB, as they only protect against respiratory droplets that are less than 5 micrometers in diameter1. However, TB bacteria can be found in larger droplets that can travel farther and infect people who are not in direct contact with the source1.
Place the client in a room with positive-pressure airflow: Positive-pressure airflow is not effective against TB, as it does not reduce the concentration of airborne particles or prevent them from escaping through cracks and gaps in doors and windows. Moreover, positive-pressure airflow can create negative pressure in other areas of the facility, which can increase the risk of cross-contamination.
Wear a surgical mask when taking the client out of the room: A surgical mask is not sufficient to protect against TB, as it only filters out particles that are larger than 5 micrometers in diameter3. It also does not fit properly on the face and may allow some particles to pass through3.
Correct Answer is D
Explanation
Choice A rationale:
Beneficence. Beneficence refers to the ethical principle of doing what is best for the client's well-being and promoting their welfare. While returning with pain medication promptly does contribute to the client's well-being, this principle does not specifically address the nurse's commitment to keeping promises or being faithful to their word.
Choice B rationale:
Utility. Utility refers to the ethical principle of seeking the greatest benefit for the greatest number of people. Fulfilling a promise to provide pain medication within the agreed-upon time frame benefits the individual client but is not necessarily related to maximizing overall utility for a broader population.
Choice C rationale:
Justice. Justice involves fairness and equitable distribution of resources and care. While ensuring timely pain relief can be seen as a just action, the concept of justice is not directly tied to keeping promises or fidelity.
Choice D rationale:
Fidelity. Fidelity, also known as "non-maleficence," centers on being faithful to commitments and maintaining trust in the nurse-client relationship. Returning with the medication as promised within 15 minutes exemplifies fidelity, as the nurse is honoring their commitment to the client's well-being and building trust through their actions.
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