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: Restricting calcium intake is not typically recommended for children with chronic renal failure as they may already be at risk for bone disease due to altered calcium metabolism.
Choice B reason: Eating three large meals per day and limiting snacks is not specific dietary advice for chronic renal failure; nutritional needs should be tailored to the individual.
Choice C reason: This is the correct choice. In chronic renal failure, the kidneys may not be able to remove excess potassium, leading to hyperkalemia, which can be dangerous.
Choice D reason: Increasing sodium intake is not generally recommended for chronic renal failure as it can contribute to hypertension and fluid retention.

A. Fasciitis B. Compartment syndrome C. Osteochondrosis D. Osteomyelitis

Correct Answer is B

Explanation

Choice A reason: Fasciitis, inflammation of the fascia, could cause pain and possibly edema, but it typically does not cause fever.

Choice B reason: Compartment syndrome is a serious condition where increased pressure within the muscles can lead to muscle and nerve damage as well as problems with blood flow. Pain, edema, and fever could be signs of this condition, especially in a limb that is in traction.

Choice C reason: Osteochondrosis refers to a group of disorders that affect the growth of bones in children and adolescents. While it can cause pain, it does not typically cause edema or fever.

Choice D reason: Osteomyelitis, an infection in the bone, could cause pain, edema, and fever. However, the acute onset of symptoms in a limb under traction is more indicative of compartment syndrome. Osteomyelitis typically has a more gradual onset.

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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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