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

Answer and Explanation

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.

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Correct Answer is B

Explanation

a) Janeway spots: Janeway lesions are painless, small, erythematous or hemorrhagic macules found on the palms or soles, characteristic of infective endocarditis, not typically associated with rheumatic fever.

b) Polyarthritis 5 + joints: Polyarthritis involving multiple joints, often migrating, is a major manifestation of acute rheumatic fever.

c) Vomiting: While nausea and vomiting can occur, they are not specific to rheumatic fever.

d) Oster nodes: Osler nodes are tender nodules found in infective endocarditis, not typically seen in rheumatic fever.

A. Hug his teddy bear when he coughs B. Blow bubbles to prevent coughing episodes C. Take a sip of apple juice before coughing D. Ask for codeine cough syrup when he coughs

Correct Answer is A

Explanation

a) Hug his teddy bear when he coughs: Splinting the chest while coughing can reduce discomfort.

b) Blow bubbles to prevent coughing episodes: Not effective for reducing cough-induced pain.

c) Take a sip of apple juice before coughing: Drinking before coughing may not significantly alleviate the discomfort.

d) Ask for codeine cough syrup when he coughs: Medication should be given based on medical advice and prescription, not as a self-request by a child.

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A nurse is planning care for a child with human immunodeficiency virus (HIV). Which nursing diagnosis is the highest priority for this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a major clinical manifestation of rheumatic fever (RF)?

Correct Answer is B

Explanation

A 3-year-old with bacterial pneumonia is crying and says it hurts when he coughs. The nurse would teach the child to do which of the following?

Correct Answer is A

Explanation

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