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 A
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
Choice A rationale:
Leaving the medication on the client's bedside table is not appropriate because it doesn't address the client's concerns and may result in the client not taking the medication at all. This choice does not promote the client's well-being.
Choice B rationale:
Returning in 1 hour to administer the medication doesn't address the client's immediate concerns and also doesn't provide adequate information about the medication's importance. Delaying the medication administration without proper communication is not ideal.
Choice C rationale:
Mixing the medication in applesauce may be appropriate in some cases, but it doesn't address the client's reluctance to take the medication due to fatigue. Additionally, the client's Crohn's disease might require specific instructions for medication administration that should not be altered without consulting the healthcare provider.
Choice D rationale:
The correct answer. Informing the client of the consequences of refusing the medication is the most appropriate action. The nurse should engage in a therapeutic conversation with the client, explaining the importance of the medication in managing Crohn's disease symptoms and preventing complications. This choice respects the client's autonomy while providing necessary information for an informed decision.
Correct Answer is B
Explanation
The correct answer is choice B: A client who has a femur fracture and reports feeling short of breath.
Choice A rationale:
A client who has facial drooping following a stroke 8 hours ago (Choice A) is a concern as it may indicate neurological damage; however, a client with a femur fracture experiencing shortness of breath takes priority due to the potential risk of a pulmonary embolism, a life-threatening complication.
Choice B rationale:
A client who has a femur fracture and reports feeling short of breath (Choice B) is the priority assessment finding. Shortness of breath in this context raises concern for a possible pulmonary embolism, which is a critical condition that requires immediate intervention.
Choice C rationale:
A client who had an appendectomy 12 hours ago and reports pain as 5 on a scale of 0 to 10 (Choice C) is a valid concern, but it is of lower priority compared to a client with a femur fracture and respiratory distress.
Choice D rationale:
A client who had an open cholecystectomy 4 days ago and has serosanguineous drainage on the wound dressing (Choice D) is a normal postoperative finding and does not require immediate attention. While wound assessment is important, it is not the priority in this scenario.
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