What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?
Risk for Altered Tissue Perfusion
Impaired Physical Mobility
Risk for Altered Nutrition: Less than Body Requirements
Risk for Fluid Imbalance
The Correct Answer is A
Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.
Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.
Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.
Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While noting the frequency of drooling is important, it is not the most critical assessment.
Choice B reason: Observing the appearance of oral mucosa is less critical than assessing the ability to swallow.
Choice C reason: Assessing speech patterns is important but secondary to swallowing ability in terms of immediate safety.
Choice D reason: This is the correct choice. The ability to chew and swallow is crucial for preventing aspiration and maintaining nutrition.
Correct Answer is C
Explanation
Choice A reason: Applying a heat pack to the bridge of the nose is not recommended as it may increase blood flow and worsen the bleeding.
Choice B reason: Lightly suctioning blood from nares and mouth is not typically necessary and could be uncomfortable for the child.
Choice C reason: This is one of the correct choices. Tilting the head forward prevents blood from flowing down the throat, which can cause nausea or vomiting.
Choice D reason: This is one of the correct choices. Sitting upright reduces blood pressure in the veins of the nose and may help slow the bleeding.
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