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igns indicating vision impairment in a child (Select All That Apply: SATA):

Frequent blinking

Imitation of facial expressions

Appropriate eye contact

Tilting the head to the side when someone whispers

Rubbing eyes

Answer and Explanation

Correct Answer : A,D,E

a) Frequent blinking: Can indicate vision strain or discomfort.

b) Imitation of facial expressions: Typically, not directly related to vision impairment.

c) Appropriate eye contact: Good eye contact might be present despite vision impairment.

d) Tilting the head to the side when someone whispers: Could indicate an attempt to better hear or see, potentially indicating vision or hearing issues.

e) Rubbing eyes: Could suggest eye discomfort or vision problems.

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Correct Answer is B

Explanation

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.

A. Hypothermia related to decreased metabolic state B. Acute pain related to the effects of a congenital heart defect C. Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect D. Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow

Correct Answer is C

Explanation

a) Hypothermia related to decreased metabolic state: Unlikely to be directly related to VSD unless it's causing severe complications affecting metabolic function.

b) Acute pain related to the effects of a congenital heart defect: While the child might experience pain due to surgery or interventions, it's not the primary nursing diagnosis for VSD.

c) Ineffective tissue perfusion (peripheral) related to cyanosis secondary to congenital heart defect: VSD causes increased workload on the heart, leading to decreased oxygenation and potentially causing cyanosis and ineffective tissue perfusion.

d) Impaired gas exchange related to pulmonary congestion secondary to the increased pulmonary blood flow: While pulmonary congestion can occur, ineffective tissue perfusion is more directly related to cyanosis from VSD.

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igns indicating vision impairment in a child (Select All That Apply: SATA):

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is B

Explanation

A nurse has admitted a child with ventricular septal defect (VSD) to the unit. Which nursing diagnosis is appropriate for this child?

Correct Answer is C

Explanation

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