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.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Providing the client with information about advance directives is an appropriate intervention. Advance directives are legal documents that allow individuals to communicate their preferences for medical treatment in the event they become unable to make decisions for themselves. Educating the client about the importance and benefits of advance directives empowers them to make informed decisions about their care.
Choice B rationale:
Encouraging the client to contact an attorney to create advance directives is not the primary responsibility of the hospice nurse. While legal assistance might be helpful, the nurse should first ensure that the client understands the concept of advance directives and their significance before suggesting legal involvement.
Choice C rationale:
Informing the client that they will need a relative to witness their advance directives is not accurate. While witnesses are often required when signing legal documents, the specific requirements for advance directives can vary by jurisdiction. It's important for the nurse to provide accurate information and not make assumptions about legal processes.
Choice D rationale:
Telling the client that The Joint Commission requires clients to have advance directives is not accurate. While The Joint Commission emphasizes the importance of patient rights and informed decision-making, it does not mandate that all clients must have advance directives. The decision to create advance directives is a personal choice and should be based on the individual's values and preferences.
Correct Answer is D
Explanation
The correct answer is choice D: Explore alternative solutions to address unit workflow with the nurses.
Choice A rationale:
Scheduling the nurses to work on alternating shifts (Choice A) might alleviate the immediate conflict, but it doesn't address the root cause of the issue, which is their perceived unequal workload. This approach could also disrupt the unit's continuity of care and potentially lead to further conflicts.
Choice B rationale:
Organizing a task force to evaluate the situation (Choice B) could be beneficial in the long run for identifying systemic issues contributing to the conflict. However, this approach might take time to yield results. In the meantime, the conflict could continue to negatively impact the unit's functioning.
Choice C rationale:
Telling the nurses that it's their responsibility to cooperate with coworkers (Choice C) is oversimplifying the situation. While cooperation is important, conflicts often arise from deeper issues that need to be addressed constructively. This choice doesn't provide a clear plan for resolving the workload disparity.
Choice D rationale:
Exploring alternative solutions to address unit workflow with the nurses (Choice D) is the most effective approach. By engaging the nurses in problem-solving discussions, the charge nurse can identify the reasons behind their perception of unfair workload distribution and collaboratively develop strategies to ensure a more equitable division of tasks. This approach promotes communication, collaboration, and shared accountability.
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