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 C
Explanation
Choice A reason: While drug overdose is a concern, it is not the leading cause of death among adolescents.
Choice B reason: Water safety and drowning are important, but they do not lead in causing deaths in this age group.
Choice C reason: This is the correct choice. Motor vehicle accidents are the leading cause of death among adolescents.
Choice D reason: Depression and suicide are significant issues, but they do not surpass motor vehicle accidents as the leading cause of death.
Correct Answer is D
Explanation
Choice A reason: While monitoring blood pressure and symptoms is important, it is not a self-management outcome.
Choice B reason: Taking up to 4 nitroglycerine tablets may be part of the treatment plan, but it is not an outcome.
Choice C reason: Encouraging daily exercise is good, but it does not address the management of chest pain on exertion.
Choice D reason: This is the correct choice. Recording episodes of angina and self-management strategies provides valuable information for adjusting treatment and empowering the patient.
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