Which nursing diagnosis takes priority for a 15-year-old child with third-degree burns of the hands, face, and chest?
Disturbed Body Image related to physical appearance
Ineffective Airway Clearance related to edema
Risk for Infection related to epidermal damage
Impaired Urinary Elimination related to fluid loss
The Correct Answer is B
Choice A reason: While a disturbed body image can impact psychological well-being, it is not the immediate priority in the acute phase of burn management.
Choice B reason: Ineffective airway clearance due to edema from burns to the face and chest poses an immediate threat to life, requiring urgent attention to maintain breathing.
Choice C reason: The risk for infection is a significant concern due to epidermal damage; however, it follows airway management in terms of immediate priorities.
Choice D reason: Impaired urinary elimination may occur due to fluid shifts after burns, but ensuring effective airway clearance is the most critical initial step in care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. There is no need for the mother to leave the room unless the child requests privacy.
Choice B reason: This choice is incorrect. While reviewing health promotion is important, it should not be the focus during a sick visit.
Choice C reason: This choice is incorrect. A comprehensive history is not necessary if the child is regularly seen and was recently assessed.
Choice D reason: This is the correct choice. The nurse should focus on the current illness reported by the mother, as the child has been regularly seen and assessed.
Correct Answer is A
Explanation
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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