A nurse in a community health clinic is assessing a client brought by their parents. Which of the following would be the highest priority nursing diagnosis?
Risk for caregiver role strain
Risk for delayed development
Sleep deprivation
Altered urinary elimination
The Correct Answer is B
Choice A reason: Caregiver role strain addresses the burden on parents or guardians. While important, it is not the highest priority compared to the client’s direct health needs. Developmental issues in a child take precedence, as they can have long-term impacts on physical, cognitive, and social growth, requiring immediate intervention.
Choice B reason: Risk for delayed development is critical in pediatric clients, as it affects cognitive, physical, and emotional growth. Early identification and intervention can mitigate long-term consequences, such as learning disabilities or social deficits. This diagnosis takes priority, as it directly impacts the child’s health and future functioning, requiring urgent attention.
Choice C reason: Sleep deprivation can affect health and development but is less urgent than developmental delays, which have broader, long-term consequences. Sleep issues may contribute to developmental problems but are typically secondary. Addressing underlying causes, like developmental risks, often resolves related symptoms like poor sleep more effectively.
Choice D reason: Altered urinary elimination, such as incontinence, may indicate a medical issue but is generally less critical than developmental delays in a pediatric client. It may be a symptom of developmental issues but does not take precedence over addressing potential delays that impact overall growth and function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hypotension occurs in hypovolemic shock when blood volume loss exceeds 15–30%, indicating a later stage. Compensatory mechanisms like vasoconstriction maintain blood pressure initially. Tachycardia precedes hypotension as the body responds to reduced volume, making it a less early sign than increased heart rate.
Choice B reason: Tachycardia is the earliest sign of hypovolemic shock, occurring with 5–15% blood volume loss. The sympathetic nervous system increases heart rate to compensate for reduced cardiac output, maintaining perfusion. This precedes other signs like hypotension or oliguria, making it the first detectable indicator in shock assessment.
Choice C reason: Cool, clammy skin results from vasoconstriction in hypovolemic shock, a compensatory response to maintain blood pressure. This occurs after tachycardia, as the body prioritizes increasing heart rate to compensate for volume loss. Skin changes are a later sign compared to the initial cardiovascular response of tachycardia.
Choice D reason: Decreased urine output (oliguria) occurs in hypovolemic shock when renal perfusion decreases, typically after significant volume loss. This is a later sign, as the kidneys receive reduced blood flow after compensatory mechanisms like tachycardia fail. Tachycardia appears earlier, as it is the body’s initial response to volume loss.
Correct Answer is A
Explanation
Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.
Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.
Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.
Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.
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