A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?
Ineffective tissue perfusion
Risk for infection
Risk for fluid volume deficit
Ineffective thermoregulation
The Correct Answer is B
a) Ineffective tissue perfusion: Though this might be a concern, the highest priority for an HIV-positive child is the risk of acquiring infections due to compromised immunity.
b) Risk for infection: HIV weakens the immune system, significantly increasing the risk of contracting infections. Preventing infections is the primary focus.
c) Risk for fluid volume deficit: While important, it's not the highest priority compared to the risk of infection due to HIV.
d) Ineffective thermoregulation: Not typically the primary concern for an HIV-positive child compared to the increased risk of infections due to the compromised immune system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a) The younger child’s airways are smaller and more easily occluded: Children, especially infants, have smaller airways, making them more susceptible to blockage during infections.
b) You are incorrect in your assessment: This response dismisses the mother's concern without providing information.
c) Air passages are more likely to become blocked with mucus due to increased mucus production in young children: While increased mucus production can be a factor, the size of airways is a more critical consideration.
d) Infants are not able to breathe deeply: Not an accurate statement; infants have a different breathing pattern but can breathe adequately.
Correct Answer is B
Explanation
a) Constipation: Not typically a primary symptom of cystic fibrosis.
b) Meconium ileus: Meconium ileus is a bowel obstruction that occurs shortly after birth due to abnormally thick meconium. It is a classic early sign of cystic fibrosis in newborns. Other symptoms such as failure to thrive, persistent cough, salty-tasting skin, and recurrent respiratory infections may also manifest later.
c) Rectal prolapse: Can be related to cystic fibrosis but is not as specific as other symptoms.
d) Steatorrhea stools: Frequent fatty stools are symptoms of the disease but not specific to cystic fibrosis.
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