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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is b. Social services.
Choice A: Occupational therapy - This is incorrect because occupational therapy focuses on improving daily living and working skills, not providing wheelchairs.
Choice B: Social services - This is the correct answer. Discharge planning begins at admission and should prepare for the functional ability of the client. This includes whether they have caregivers at home, or if they’re in need of one. A referral for social services can be made as needed to address gaps in the clients support system or resources.
Choice C: Home health - This is incorrect because home health provides medical treatment, not equipment like wheelchairs.
Choice D: Physical therapy - This is incorrect because physical therapy helps improve mobility and strength, but does not provide wheelchairs.
Correct Answer is B
Explanation
Choice A rationale:
Request crutches from a medical equipment provider. This choice is not appropriate for a client with left-sided weakness due to a stroke. Crutches are primarily used for lower extremity support and would not address the client's mobility and safety needs related to their left-sided weakness.
Choice B rationale:
Advise the client to install grab bars in the bathroom at home. This is the correct choice. Installing grab bars in the bathroom will enhance the client's safety and independence. Left-sided weakness can result in balance issues, and having grab bars near the toilet and in the shower can help prevent falls and provide the client with support while using these facilities. This intervention promotes the client's functional autonomy and reduces the risk of injury.
Choice C rationale:
Encourage the client to allow a home care aide to perform ADLs for them. While it might be necessary for a client with severe disability to receive assistance with Activities of Daily Living (ADLs), the question does not provide enough information to suggest that the client's condition warrants this level of intervention. Encouraging independence is generally preferred to maintain the client's self-esteem and engagement in daily life activities.
Choice D rationale:
Contact hospice to provide follow-up care for the client. Hospice care is intended for clients with terminal illnesses who are in the final stages of life. A client who has had a stroke and is experiencing left-sided weakness does not automatically qualify for hospice care. The client's condition can be managed with rehabilitation and support, and hospice care is not appropriate in this context.
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