A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?

Ineffective tissue perfusion

Risk for infection

Risk for fluid volume deficit

Ineffective thermoregulation

Answer and Explanation

The Correct Answer is B

a) Ineffective tissue perfusion: Though this might be a concern, the highest priority for an HIV-positive child is the risk of acquiring infections due to compromised immunity.

b) Risk for infection: HIV weakens the immune system, significantly increasing the risk of contracting infections. Preventing infections is the primary focus.

c) Risk for fluid volume deficit: While important, it's not the highest priority compared to the risk of infection due to HIV.

d) Ineffective thermoregulation: Not typically the primary concern for an HIV-positive child compared to the increased risk of infections due to the compromised immune system.

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Correct Answer is C

Explanation

a) The infant having a higher basal metabolic rate: Basal metabolic rate doesn't directly impact urine specific gravity.

b) The infant’s kidneys being less able to concentrate urine: In fact, infants have immature kidneys that are less efficient at concentrating urine, but this is not the primary reason for lower specific gravity.

c) The infant having a greater percentage of body weight in water: Infants have a higher percentage of body weight in water, leading to more dilute urine.

d) The infant having a greater body surface area: While body surface area influences some aspects of renal function, it's not the main factor affecting urine specific gravity in infants.

A. The infant has blood in urine B. The infant has received two doses of morphine per PRN orders C. The infant has voided one time since returning from surgery D. Double diapering the infant has resulted in the stent being free from stool contamination

Correct Answer is A

Explanation

a) Blood in the urine after hypospadias repair could indicate postoperative bleeding, and it's a significant finding that should be reported promptly to the surgeon.

b) Administration of morphine according to PRN orders is a common postoperative pain management strategy and might not require immediate reporting unless there are concerns about the dosage or the child's response.

c) Voiding once after surgery is expected and not necessarily concerning unless there are additional issues or complications.

d) Ensuring the stent is free from stool contamination is important for postoperative care but doesn't require immediate reporting to the surgeon unless there are signs of infection or other complications.

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A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?

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Naxlex Comprehensive Predictor Exams

A nurse notes that the specific gravity of urine is lower in infants than in older children. The nurse recognizes that the rationale for this difference is related to:

Correct Answer is C

Explanation

Following a hypospadias repair, the 10-month-old child returns from the operating room with a urethral stent. It is now 8 hours since the child’s surgery. Which assessment finding should be reported to the surgeon?

Correct Answer is A

Explanation

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