A nurse is prioritizing care for four clients.
Which of the following clients should the nurse assess first?
adolescent who is in skin traction and reports pain level of 7 on a scale of 0 to 10
adolescent who has sickle cell anemia and slurred speech
toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus
toddler who has partial burn thickness burns on the right hand and requires a dressing change .
The Correct Answer is B
When prioritizing care for multiple clients, the nurse should first assess the client who is most unstable and has the most urgent needs. In this case, the adolescent with sickle cell anemia and slurred speech should be assessed first. Slurred speech could indicate a stroke, which is a life-threatening condition that requires immediate medical attention. The other clients, while they also require care, are not in immediate danger and can be assessed after the adolescent with sickle cell anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
For a lumbar puncture, the child should be placed in the lateral position. This position allows for better access to the spinal canal, which is necessary for a lumbar puncture.
Correct Answer is B
Explanation
Choice A rationale
A child’s weight being in the 45th percentile is within the normal range and is not in itself an indicator of physical abuse.
Choice B rationale
Bruising around the wrists can be a potential indicator of physical abuse. Unexplained bruises, particularly in unusual locations or in specific patterns, can be a sign of physical abuse.
Choice C rationale
Abrasions on the knees are common in children due to normal play and activity and are not typically an indicator of physical abuse.
Choice D rationale
Missing front deciduous teeth in a 7-year-old student is not typically an indicator of physical abuse. It is normal for children to begin losing their deciduous (baby) teeth around this age.
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