A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

The child has red fissures at the corners of the mouth.

The child has several small bruises on both legs.

The child sleeps for about 13 hours each night.

The child is not regularly attending school.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The child having red fissures at the corners of the mouth is not the priority finding. While this could indicate a nutritional deficiency, such as vitamin B2 (riboflavin) deficiency, the presence of bruises on the child's legs raises more immediate concerns related to potential physical abuse or safety issues.

Choice B rationale:

The child having several small bruises on both legs is the priority finding. Bruising on a school-age child could indicate physical abuse or an unsafe living environment. Ensuring the child's safety and well-being takes precedence over other findings. Assessing the nature, pattern, and explanation for the bruises is crucial.

Choice C rationale:

The child sleeping for about 13 hours each night is not the priority finding in this scenario. While sleep patterns are important, the potential for physical abuse and safety concerns associated with the bruises takes precedence.

Choice D rationale:

The child not regularly attending school is a concern, but it is not the priority finding when compared to the possibility of physical abuse indicated by the bruises. Both issues need to be addressed, but ensuring the child's immediate safety is the primary focus.

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Correct Answer is D

Explanation

Choice A rationale: Providing information about other birth control methods is appropriate after the nurse explores the client's uncertainty, as it ensures the client's decision-making process is supported by understanding all available options.

Choice B rationale: While involving a partner can be helpful, the nurse’s primary responsibility is to the client’s autonomy; asking this first may shift the focus away from the client’s personal concerns.

Choice C rationale: Emphasizing only the benefits is non-therapeutic and biased. The nurse must remain neutral and allow the client to weigh both the benefits and risks of a permanent procedure.

Choice D rationale: Active listening and exploring the client's feelings are the first steps in the nursing process to address uncertainty. This allows the client to clarify their values and reach an informed decision.

A. Set target dates for completion. B. Identify areas of support. C. Determine goals and objectives. D. Implement recommended strategies.

Correct Answer is C

Explanation

Choice A rationale:

Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.

Choice B rationale:

Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.

Choice C rationale:

Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.

Choice D rationale:

Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.

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A nurse is developing a plan of care for a school-age child whose family is homeless. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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