A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Paralytic ileus

Fluid imbalance

Airway obstruction

Infection

Answer and Explanation

The Correct Answer is C

A. Paralytic ileus may occur due to shock or stress but is not the immediate priority.

B. Fluid imbalance is critical but is secondary to airway patency in this case.

C. Airway obstruction is the most immediate concern due to the location of the burns, which can cause swelling and compromise breathing.

D. Infection risk is high with burns but is less immediate than airway maintenance.

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Correct Answer is D

Explanation

A. Wrapping from the knee down is incorrect; the ankle should be wrapped from the toes up to provide proper compression.

B. Heat is not recommended immediately after a sprain, as it may increase swelling.

C. Bearing weight on the ankle too soon could worsen the injury.

D. Applying ice for the first 48 hours helps reduce swelling and pain, so this is the correct statement.

A. Psychotherapy for the unaffected children in the family B. Therapy for the child C. Establishing safety of the child D. Obtaining treatment for the mother

Correct Answer is C

Explanation

A. Psychotherapy for other family members is essential but not the immediate priority.

B. Therapy for the child is beneficial but secondary to ensuring immediate safety.

C. Ensuring the child's safety is the top priority in suspected abuse cases to prevent further harm.

D. Treatment for the mother (e.g., psychiatric care) is necessary but secondary to child protection.

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A nurse in the emergency department is caring for a 10-year old child who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discharging a 12 year old client who came to the outpatient clinic with an ankle sprain with their parent. Which of the following statements should the nurse identify as an indication that the client and parent understand the discharge instructions?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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