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A child who is visibly anxious and withdrawn while in the hospital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 ["B","C"]
Explanation
The nurse should plan to include Target 1: administer acetaminophen or ibuprofen oral solution if needed for pain and Target 2: call provider if right leg feels cool to touch in comparison to left leg in the discharge instructions for the guardians.
Rationale:
- Administer acetaminophen or ibuprofen oral solution if needed for pain: This instruction is important for managing post-procedure discomfort and promoting the child's comfort.
- Call provider if right leg feels cool to touch in comparison to left leg: This is a critical instruction, as it can indicate potential complications like bleeding or thrombosis. Early identification of these issues is essential for timely intervention.
The other options are not appropriate for discharge teaching in this case:
- Remove pressure dressing four hours after discharge: This is typically done in the hospital setting under the supervision of healthcare professionals.
- Maintain clear liquid diet for 24 hr after discharge: A clear liquid diet may not be necessary after discharge, especially if the child is tolerating oral intake well.
- Tub bath is permitted 24 hr after procedure: While bathing is generally allowed after the procedure, specific instructions regarding water temperature and avoiding submerging the incision site should be provided.
Correct Answer is C
Explanation
A. Bradycardia is not typically expected in toddlers with heart failure; instead, tachycardia (increased heart rate) is more common as the body compensates for decreased cardiac output.
B. Weight loss is generally not a typical finding in toddlers with heart failure; rather, they often experience weight gain due to fluid retention.
C. Orthopnea, or difficulty breathing when lying flat, is a common symptom of heart failure and would be expected in a toddler due to fluid overload affecting respiratory function.
D. Increased urine output is usually not expected in heart failure; rather, fluid retention often leads to decreased urine output as the kidneys respond to the body's fluid balance needs.
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