A nurse is receiving a change-of-shift report for a group of clients.
Which of the following clients should the nurse plan to see first?
A toddler who has coarctation of the aorta and weak pedal pulses.
A school-age child who has rheumatic fever and an increased erythrocyte sedimentation rate.
A school-age child who has endocarditis and a new onset of lethargy.
A toddler who has Kawasaki disease and erythema of the lips.
The Correct Answer is C
Choice A rationale
Weak pedal pulses in coarctation of the aorta indicate impaired blood flow distal to the narrowed area but do not indicate immediate deterioration. Chronic coarctation causes gradual compensatory mechanisms, and absent urgent changes, this case is less critical compared to acute presentations in other choices.
Choice B rationale
Rheumatic fever elevates erythrocyte sedimentation rate (ESR) due to inflammation, but this alone does not indicate acute danger. ESR reflects systemic inflammation rather than life-threatening symptoms, which makes this patient a lower priority unless accompanied by other significant changes.
Choice C rationale
New onset lethargy in endocarditis suggests possible septic emboli or worsening infection, which can rapidly progress to critical complications. Lethargy often indicates systemic compromise or reduced perfusion, which requires immediate attention compared to chronic or stable cases in other options.
Choice D rationale
Kawasaki disease presents erythema of the lips due to systemic vasculitis, but this finding alone does not indicate acute deterioration. The condition is serious but relatively stable without additional evidence of impending coronary complications, making this client less urgent than Choice C.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Educating about phantom limb pain is crucial for long-term coping and understanding of post-amputation effects. However, it does not address the immediate physical health risks like infection that must be managed first to ensure recovery.
Choice B rationale
Inspection of the incision site is necessary to monitor for infection, ensuring immediate postoperative complications are addressed. Prompt recognition of signs like redness, swelling, or purulent discharge prevents systemic infection and optimizes wound healing.
Choice C rationale
Range-of-motion exercises aim to maintain flexibility and prevent contractures. While integral to rehabilitation, they are not an immediate priority in the acute postoperative period when infection is a more urgent concern.
Choice D rationale
Placing the child in the prone position helps prevent contractures in the hip flexors but does not address immediate concerns of infection. It is a preventative measure rather than an acute care priority.
Correct Answer is B
Explanation
Choice A rationale
The Color tool is visually engaging but less effective for infants, as it is more suitable for children who can comprehend abstract concepts.
Choice B rationale
The FLACC scale assesses Face, Legs, Activity, Cry, and Consolability, providing an objective evaluation of pain intensity in non-verbal populations, such as infants postoperatively.
Choice C rationale
The Numeric scale requires the cognitive ability to comprehend numerical values, making it inappropriate for an 18-month-old infant.
Choice D rationale
The Poker Chip tool relies on symbolic reasoning and is generally used for older children, who can understand abstract representation.
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