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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: School-age children, typically around the ages of 6 to 12, begin to grasp the finality and irreversibility of death. They understand that death is universal and affects all living things.
Choice B reason: Preschool-age children may have some concept of death, but they often view it as reversible or temporary, not fully understanding its permanence.
Choice C reason: Toddlers are too young to comprehend the concept of death, as their cognitive development at this stage does not allow for such abstract thinking.
Choice D reason: While adolescents certainly understand the permanence of death, this awareness develops earlier, during the school-age years. Adolescents may begin to explore more complex philosophical and existential questions about life and death.
Correct Answer is C
Explanation
Choice A reason: Escorting the parents out of the room may increase their anxiety and distress, as they may want to be close to their child during such a critical time.
Choice B reason: Allowing one parent to sit on the bed may interfere with the medical team's efforts and is not typically recommended during active resuscitation.
Choice C reason: Allowing the parents to stay in the room can provide them with some comfort, knowing they are near their child, and may help in the grieving process if the outcome is unfavorable, as long as they do not interfere with the medical procedures.
Choice D reason: Bringing additional family members into the room during resuscitation can create a chaotic environment and may hinder the medical team's ability to work efficiently. It is better to have a controlled number of people in the room.
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