A nurse is providing care for a group of hospitalized school-aged children. Which of the following clients should the nurse prioritize for further assessment and interventions?
A child who is visibly anxious and withdrawn while in the hospital
A child whose vital signs are stable whose parent expresses concerns about the disruption to the child's routine
A child who is experiencing stomach pain without an apparent cause
A child who is exhibiting aggressive behavior towards peers and healthcare providers
The Correct Answer is D
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.
Correct Answer is B
Explanation
A. This statement is incorrect; the spacer does not primarily increase medication delivery to the oropharynx.
B. The spacer helps to increase the amount of medication that reaches the lungs by allowing larger particles to settle out and preventing them from being deposited in the mouth and throat.
C. Inhaling slowly and deeply is recommended for effective medication delivery when using an MDI with a spacer.
D. Covering the exhalation slots would prevent proper airflow and could cause the child to inhale exhaled air, which is not recommended during inhalation.
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