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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: pH 7.48, PaCO2 40 mmHg, HCO3- 24 mEq/L indicates alkalosis, not acidosis. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to ketone accumulation, lowering pH and bicarbonate. Normal PaCO2 and HCO3- rule out DKA, as compensatory hyperventilation would lower PaCO2 in response to acidosis.

Choice B reason: pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L indicates metabolic acidosis with respiratory compensation. In DKA, ketone production lowers pH and bicarbonate, while hyperventilation reduces PaCO2 to compensate. These values align with DKA’s acid-base imbalance, reflecting the body’s attempt to correct acidosis through increased respiration.

Choice C reason: pH 7.50, PaCO2 45 mmHg, HCO3- 30 mEq/L indicates metabolic alkalosis, not acidosis. DKA causes acidosis from ketone accumulation, not alkalosis. Elevated bicarbonate and normal PaCO2 suggest a different condition, like vomiting-induced alkalosis, making this inconsistent with the metabolic acidosis seen in DKA.

Choice D reason: pH 7.35, PaCO2 38 mmHg, HCO3- 22 mEq/L indicates normal acid-base balance. DKA results in metabolic acidosis with low pH and bicarbonate due to ketone production. Normal values do not reflect the acidotic state of DKA, where compensatory mechanisms would alter PaCO2 and HCO3- significantly.

A. Mild itching at the infusion site B. Slight increase in heart rate C. Sudden chills and fever D. Minor redness around the IV site

Correct Answer is C

Explanation

Choice A reason: Mild itching may indicate a minor allergic reaction to a transfusion, caused by sensitivity to donor plasma proteins. While concerning, it is not immediately life-threatening and can often be managed with antihistamines. Severe symptoms like fever and chills take priority, as they suggest more dangerous reactions like hemolytic or febrile responses.

Choice B reason: A slight increase in heart rate can occur due to anxiety or fluid volume changes during transfusion but is not specific to a transfusion reaction. It is less urgent than fever and chills, which indicate a potentially severe reaction like hemolysis or infection, requiring immediate cessation of the transfusion.

Choice C reason: Sudden chills and fever during a transfusion suggest a febrile non-hemolytic reaction or, more critically, a hemolytic reaction or sepsis. These can cause systemic inflammation, hemolysis, or shock, requiring immediate stopping of the transfusion, assessment, and intervention to prevent life-threatening complications like renal failure or disseminated intravascular coagulation.

Choice D reason: Minor redness at the IV site may indicate local irritation or phlebitis, not a systemic transfusion reaction. It is less urgent than systemic symptoms like fever and chills, which signal severe reactions requiring immediate action. Local symptoms can be monitored and managed without stopping the transfusion.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas result is most consistent with this condition?

Correct Answer is B

Explanation

A nurse is monitoring a client receiving a blood transfusion. Which symptom indicates a potential transfusion reaction that requires immediate action?

Correct Answer is C

Explanation

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?

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