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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Taking the child on a tour might be overwhelming and increase anxiety due to the new environment and sensory overload.

Choice B reason: Placing the child in a four-bed room could lead to overstimulation and discomfort due to the presence of multiple unfamiliar people.

Choice C reason: Orienting the child to the hospital room provides a safe and controlled environment, allowing for gradual adjustment to the new setting.

Choice D reason: Immediately taking the child to the playroom for arts and crafts might be too stimulating and could exacerbate stress rather than ease the transition.

A. An orogastric tube fails to pass at birth. B. The infant has a low birth weight. C. It is visually identified at the time of delivery. D. Dry mouth and nares, little to no oral secretions at delivery.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. If an orogastric tube fails to pass, it may indicate a blockage or abnormal connection, such as a tracheoesophageal fistula.
Choice B reason: Low birth weight can be associated with many conditions and is not specific to TEF.
Choice C reason: TEF is not typically visible without special imaging or procedures; it cannot be visually identified at delivery.
Choice D reason: Dry mouth and nares with little to no oral secretions could indicate other conditions and are not specific to TEF. TEF often presents with excessive oral secretions.

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What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

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Naxlex Comprehensive Predictor Exams

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