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 A
Explanation
The correct answer is choice A: Compare data from clients' records regarding skin integrity with established criteria.
Choice A rationale:
Comparing data from clients' records regarding skin integrity with established criteria (Choice A) is essential for evaluating the effectiveness of the plan to decrease pressure injuries. This action helps identify trends, improvements, or areas that still need attention.
Choice B rationale:
Measuring staff attendance at an educational program on managing pressure injuries (Choice B) assesses staff participation but does not directly evaluate the plan's impact on pressure injury rates. Attendance does not necessarily translate to improved implementation.
Choice C rationale:
Interviewing clients regarding their satisfaction with their care (Choice C) focuses on client satisfaction rather than evaluating the effectiveness of the plan in reducing pressure injuries. While satisfaction is important, it does not directly measure the plan's success.
Choice D rationale:
Monitoring use of supplies used to prevent pressure injuries (Choice D) provides information on resource utilization but does not provide comprehensive data on the plan's effectiveness. It does not account for the effectiveness of staff adherence to pressure injury prevention protocols.
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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