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: 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.
Correct Answer is D
Explanation
Choice A reason: This statement is correct; early treatment for clubfoot is essential for the best outcomes.
Choice B reason: The parent's understanding of the need for long-term follow-up care until skeletal maturity is accurate.
Choice C reason: Regular visits for new casts are part of the standard treatment protocol for clubfoot.
Choice D reason: This statement indicates a misunderstanding. Clubfoot treatment typically involves a series of casts changed more frequently than 8-10 weeks apart, not a single spica cast for that duration. Further teaching is needed to correct this misconception.
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