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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hyperchloremia, elevated chloride levels, is associated with metabolic acidosis or dehydration, not neuromuscular symptoms like wrist flexion. Chloride imbalances affect acid-base balance, not calcium-dependent muscle contractions. The inward wrist flexion suggests a neuromuscular excitability issue, which is more characteristic of low calcium levels than chloride abnormalities.
Choice B reason: Hypercalcemia, high calcium levels, causes muscle weakness, lethargy, and reduced reflexes, not increased neuromuscular excitability like wrist flexion. Calcium excess stabilizes nerve membranes, reducing spasms. The symptom described aligns with hypocalcemia, where low calcium increases nerve excitability, leading to tetany or abnormal muscle contractions.
Choice C reason: Hypocalcemia, low calcium levels, increases neuromuscular excitability due to decreased stabilization of nerve membranes. This can cause tetany, characterized by involuntary muscle contractions, such as wrist flexion (carpopedal spasm). The symptom is a classic sign of hypocalcemia, often seen in conditions like hypoparathyroidism or vitamin D deficiency.
Choice D reason: Hypomagnesemia, low magnesium, can cause neuromuscular symptoms like tremors or seizures but is less commonly associated with specific signs like wrist flexion. Magnesium affects muscle relaxation, and its deficiency typically causes generalized excitability. Hypocalcemia is more directly linked to tetany and carpopedal spasms, as seen in the client.
Correct Answer is C
Explanation
Choice A reason: The cognitive domain involves knowledge and understanding, such as explaining the procedure or its rationale. The client’s statement indicates understanding (“I understand”), so their concern is not about knowledge but emotional worries about pain and appearance, which are better addressed in the affective domain to provide emotional support.
Choice B reason: The psychomotor domain focuses on physical skills, like performing a task or procedure. The client’s concerns about pain and appearance are emotional, not skill-based. Addressing psychomotor skills, such as teaching self-care techniques, is irrelevant to the client’s expressed emotional worries, requiring a focus on feelings instead.
Choice C reason: The affective domain involves emotions, attitudes, and feelings. The client’s worries about pain and appearance post-mastectomy reflect emotional concerns. Addressing this domain through empathetic listening and emotional support helps alleviate anxiety, validates feelings, and fosters coping, making it the most appropriate focus for the nurse’s response.
Choice D reason: The behavioral domain is not a standard learning domain in nursing education (cognitive, psychomotor, affective are typical). If interpreted as behavior modification, it is irrelevant here, as the client’s concerns are emotional, not behavioral. The nurse should focus on addressing the client’s feelings rather than attempting to change behaviors.
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