A nurse on a pediatric unit is planning care for a group of clients. Which client should the nurse plan to assess first?

A toddler who is scheduled for an upper gastrointestinal x-ray series.

A school-age child who has diabetes mellitus and requires blood glucose monitoring.

An adolescent who is one day status-post an appendectomy.

An infant who has pertussis and is receiving oxygen via nasal cannula

Answer and Explanation

The Correct Answer is D

Pertussis, or whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis, characterized by paroxysmal coughing and inspiratory "whoops." In infants, the disease is particularly severe due to the risk of apnea, encephalopathy, and secondary pneumonia. Clinical priority is directed toward maintaining airway patency and ensuring adequate oxygenation, as small children possess limited physiological reserves to compensate for acute respiratory distress or hypoxic episodes.

Rationale:

A. A scheduled diagnostic procedure like a gastrointestinal x-ray is a routine event that does not indicate an acute physiological crisis. While the child may be fasting, their status is stable and predictably managed within the standard daily workflow of a pediatric unit. This client does not require immediate, life-saving assessment before those with compromised respiratory function.

B. Routine glucose monitoring for a child with diabetes is a standard part of managing a chronic metabolic condition. Unless the child is displaying signs of severe hypoglycemia or ketoacidosis, such as altered mental status or Kussmaul respirations, they remain a lower priority. The nurse can delegate or perform this task after stabilizing patients with higher acuity.

C. A patient who is 24 hours post-appendectomy is in the recovery phase of a surgical intervention. While they require assessment for bowel sounds and incision integrity, they are typically stable and transitioning to oral intake and ambulation. This client’s needs are predictable and do not take precedence over an infant experiencing an active respiratory infection.

D. The infant with pertussis represents the highest priority due to the potential for sudden airway obstruction or life-threatening apneic spells. Being on supplemental oxygen indicates an impaired gas exchange status that requires frequent, close monitoring of pulse oximetry and respiratory effort. The nurse must assess this child first to ensure the current oxygen delivery is sufficient to prevent cyanosis.

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Correct Answer is B

Explanation

Post-exposure management of human immunodeficiency virus involves urgent initiation of post-exposure prophylaxis (PEP) within 72 hours of exposure to reduce viral replication and prevent systemic infection. HIV targets CD4+ T lymphocytes leading to progressive immunodeficiency syndrome, characterized by opportunistic infections and immune system collapse if untreated.

Rationale:

A. Immediate HIV testing after exposure identifies baseline status but does not address viral replication prevention. Early testing is necessary but not sufficient as antibody formation may not yet be detectable during the window period. Follow-up testing, not immediate results, determines seroconversion.

B. Post-exposure prophylaxis requires a 28-day antiretroviral regimen to inhibit viral replication and reduce risk of seroconversion. Early initiation within 72 hours significantly decreases infection probability. This is the evidence-based standard of care following high-risk HIV exposure.

C. There is no available HIV vaccine for post-exposure prevention. Vaccination does not exist for HIV due to viral mutation and immune evasion mechanisms. This statement reflects incorrect information regarding HIV prevention strategies.

D. Serial HIV testing is required during the window period, but testing every 2 weeks for 6 months is not standard protocol. Recommended follow-up typically occurs at baseline, 6 weeks, 3 months, and 6 months, combined with PEP initiation rather than surveillance alone.

A. Verbalize having a sense of control over behaviors. B. Acknowledge misperceptions about body image. C. Attain a weight that is greater than the 75th percentile for ideal body weight. D. Identify changes within the client's family unit that promote the client's autonomy.

Correct Answer is C

Explanation

Severe malnutrition in anorexia nervosa triggers electrolyte imbalances, specifically hypokalemia and hypomagnesemia, which disrupt myocardial electrical conduction. This state of metabolic instability leads to bradycardia and lethal dysrhythmias. Physiological restoration of nutritional homeostasis is the immediate life-saving priority over psychological or family-based interventions.

Rationale:

A. Establishing a sense of control is a vital long-term psychotherapeutic objective for recovery from eating disorders. However, psychological milestones are secondary to physiological stabilization when life-threatening arrhythmias are present. The nurse must prioritize physical survival before addressing behavioral or cognitive autonomy issues.

B. Addressing body dysmorphia is essential for resolving the cognitive distortions that drive restrictive eating behaviors. Despite its importance in psychiatric rehabilitation, it does not mitigate the immediate mortality risk associated with cardiac instability. Physiological needs always take precedence over psychosocial needs in the acute clinical setting.

C. Restoring body weight is the priority to reverse myocardial atrophy and correct the biochemical deficiencies causing arrhythmias. Reaching a safe weight threshold facilitates cardiac recovery and prevents sudden death. This goal addresses the most acute threat to the client’s physical integrity and survival.

D. Enhancing family dynamics and promoting autonomy are components of systemic therapy used during the maintenance phase. While these promote long-term resilience, they do not resolve the acute starvation state or the current cardiac emergency. Clinical focus must remain on biological stabilization during the initial hospitalization phase.

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A nurse on a pediatric unit is planning care for a group of clients. Which client should the nurse plan to assess first?

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Naxlex Comprehensive Predictor Exams

A community health nurse is caring for a client who was exposed to the human immunodeficiency virus (HIV) 2 days ago. The client asks the nurse what she should do. Which response should the nurse make?

Correct Answer is B

Explanation

A nurse is planning care for a client who has anorexia nervosa and has been admitted for cardiac arrhythmias. Which client goal should the nurse identify as the priority?

Correct Answer is C

Explanation

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