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 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.

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Correct Answer is D

Explanation

Choice A rationale:

A client who has a penetrating head injury and a respiratory rate of 4/min requires immediate attention due to the critical nature of the head injury and the dangerously low respiratory rate. However, in an emergency situation like this, the priority would be a condition that could be rapidly fatal if not addressed promptly.

Choice B rationale:

A client with a comminuted fracture of the femur has a serious injury that requires assessment and treatment, but it is not an immediately life-threatening condition. It falls lower in the priority compared to conditions that directly impact respiratory and cardiovascular function.

Choice C rationale:

A client with a 15.2-cm laceration to the scalp with clotted blood visible also requires attention, but it is not as time-sensitive as a life-threatening condition. Controlling bleeding and cleaning the wound can be addressed after addressing more critical cases.

Choice D rationale:

Correct. A client with a sucking chest wound has a high risk of tension pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse and compromised circulation. This condition can be rapidly fatal. Immediate intervention is required to seal the wound and prevent further air from entering the pleural space.

A. The right to be treated with respect and dignity. B. The right to full access of the facility. C. The right to refuse their medications. D. The right to leave regardless of provider recommendations. E. The right to be fully informed of their health conditions.

Correct Answer is ["A","C","D","E"]

Explanation

The correct answers are choices A, C, D, and E:

Choice A rationale: The right to be treated with respect and dignity is a fundamental client right in any healthcare setting, including long-term care facilities. This right ensures that clients receive care in a compassionate and respectful manner.
Choice B rationale: Full access to the facility is not a standard client right in long-term care facilities. Access to certain areas might be restricted for safety reasons or to maintain privacy.
Choice C rationale: The right to refuse medications is an essential aspect of client autonomy, allowing clients to make informed decisions about their care. It is important to address this right during orientation.
Choice D rationale: The right to leave regardless of provider recommendations is another aspect of client autonomy. Clients should be informed of their right to refuse care or leave the facility if they wish, even if it goes against the advice of healthcare providers.
Choice E rationale: The right to be fully informed of their health conditions is a crucial aspect of client autonomy and transparency in healthcare. Clients should be aware of their health status and treatment options to make informed decisions about their care.

In conclusion, when conducting an orientation class for new clients and their families at a long-term care facility, the nurse should address the rights to be treated with respect and dignity, refuse medications, leave the facility (even if it is against the recommendations of healthcare providers), and be fully informed of their health conditions.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is admitting clients following an earthquake. The emergency disaster plan has been implemented due to the anticipated arrival of a large number of casualties. Which of the following clients should the nurse recommend the provider evaluate first?

Correct Answer is D

Explanation

A nurse is conducting an orientation class for new clients and their families at a long-term care facility. Which of the following client rights should the nurse address at the orientation? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

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