A 5-year-old child is admitted to the emergency department with partial-thickness burns covering the face and neck after a kitchen accident.
Which assessment should the nurse prioritize upon the child's arrival?
Observing for signs of respiratory distress.
Monitoring vital signs for indications of shock.
Obtaining a detailed history of the burn incident.
Evaluating the extent and depth of the burns.
The Correct Answer is A
Choice A rationale
Observing for signs of respiratory distress is the priority assessment for a child with burns to the face and neck. Burns in this area can lead to airway edema and compromise, which can rapidly become life-threatening. Assessing for stridor, hoarseness, difficulty breathing, and changes in respiratory rate and effort is crucial for immediate intervention.
Choice B rationale
Monitoring vital signs for indications of shock is important in burn patients due to fluid shifts and potential hypovolemia. However, airway patency takes precedence, as inadequate oxygenation will quickly lead to irreversible damage. Vital signs should be monitored continuously after ensuring the airway is secure.
Choice C rationale
Obtaining a detailed history of the burn incident is necessary for understanding the mechanism of injury and potential associated trauma. However, the immediate priority is to assess and manage any threats to the child's airway, breathing, and circulation. History taking can occur once the child is stable.
Choice D rationale
Evaluating the extent and depth of the burns is crucial for determining the severity of the injury and guiding fluid resuscitation and wound care. However, ensuring a patent airway and adequate breathing is the immediate priority upon the child's arrival in the emergency department.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
At 12 months, a child typically says their first single words with meaning, such as "mama" or "dada," and may understand simple commands. Reaching a vocabulary of 50 words is not expected at this early stage of language development.
Choice B rationale
By 24 months, most toddlers have experienced a significant language explosion and are typically able to say at least 50 words and are beginning to combine two words into simple phrases. This is a key milestone in language development.
Choice C rationale
At 36 months, a child's vocabulary has typically expanded significantly, often exceeding several hundred words. They are also using longer and more complex sentences. Saying only 50 words at this age would be considered a developmental delay.
Choice D rationale
At 15 months, children are typically in the stage of building their vocabulary beyond the initial single words. While some may be approaching a larger vocabulary, consistently saying 50 words is more characteristic of older toddlers closer to 24 months.
Correct Answer is A
Explanation
Choice A rationale
Cryptorchidism is the medical term for the failure of one or both testicles to descend into the scrotum. The scenario describes a 2-year-old male with one non-palpable testicle, which is the hallmark of cryptorchidism. Risk factors include prematurity and low birth weight.
Choice B rationale
An inguinal hernia is a protrusion of abdominal contents through the inguinal canal. While it can present as a swelling in the groin area, it is distinct from a missing testicle in the scrotum. Examination would typically reveal a palpable mass that may reduce with gentle pressure.
Choice C rationale
A hydrocele is a collection of fluid within the tunica vaginalis, the sac surrounding the testicle. It typically presents as a painless swelling of the scrotum. The testicle is usually palpable within the fluid-filled sac.
Choice D rationale
Testicular torsion is a medical emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testicle. It presents with sudden, severe scrotal pain, swelling, and often nausea and vomiting. The examination would reveal a tender, firm, and retracted testicle. .
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