Four students come to the school clinic simultaneously, seeking help from the school nurse. In which order of priority should the nurse provide care to these students? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)
A 12-year-old child with history of asthma who is wheezing and reporting shortness of breath.
A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.
A 10-year-old child with bleeding lacerations on both knees after falling in gym class.
A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
The Correct Answer is A,B,C,D
1. A 12-year-old child with a history of asthma who is wheezing and reporting shortness of breath.
Rationale: The child with asthma who is wheezing and experiencing shortness of breath is the highest priority. Wheezing and shortness of breath are signs of a potentially severe asthma exacerbation, which can quickly become life-threatening if not addressed promptly. Immediate intervention is needed to ensure adequate oxygenation and prevent further respiratory distress.
2. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness
Rationale: The child with type 1 diabetes mellitus who is experiencing extreme hunger and shakiness may be showing symptoms of hypoglycemia, which can also be potentially dangerous. While not as immediately life-threatening as severe respiratory distress, hypoglycemia needs to be addressed quickly to prevent complications such as loss of consciousness or seizures.
3. A 10-year-old child with bleeding lacerations on both knees after falling in gym class.
Rationale: The child with bleeding lacerations requires prompt care to manage the bleeding and prevent infection. However, this situation is less critical compared to the respiratory distress and hypoglycemia, which have more immediate implications for the child’s health.
4. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
Rationale: While the child’s distress and the need for clean-up are important, this situation is the least urgent in terms of immediate health risks compared to the other three cases. Addressing the child’s comfort and hygiene can follow after more critical needs are met.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Teach clients about recommended immunizations for children:
Teaching about immunizations is a form of primary prevention, as it aims to prevent diseases before they occur. It is not classified as tertiary prevention.
B. Instruct teens about prevention of sexually transmitted diseases:
Instructing about the prevention of sexually transmitted diseases (STDs) is a form of secondary prevention. It focuses on preventing the spread of disease and identifying it early.
C. Take blood pressures at a local shopping mall in the community:
Measuring blood pressure is an example of secondary prevention, which involves screening for health issues to detect them early. It does not fall under tertiary prevention, which focuses on managing existing conditions.
D. Demonstrate foot care to a group of clients who have diabetes:
Demonstrating foot care to clients with diabetes is an example of tertiary prevention. It involves managing and preventing complications in individuals who already have a chronic condition (diabetes). This helps in minimizing the impact of the disease and improving the quality of life for those affected.
Correct Answer is D
Explanation
A) Instruct on technique of "stop, drop & roll" at assembly:
This is a primary prevention intervention aimed at educating students on how to prevent burns in the event of a fire. It does not address a specific identified problem but rather provides general safety education.
B) Involve the parent teacher association (PTA) in a fund raising event for the new gym:
This action focuses on raising funds for a new gym, which is related to school improvement and development rather than addressing an immediate health issue. It does not fall under secondary intervention for an identified problem.
C) Invite 1st grade parents to a "Meet the Teachers" event:
This intervention focuses on fostering relationships between parents and teachers and improving school engagement. While valuable, it does not address a specific health problem that requires secondary intervention.
D) Send letters to parents regarding a recent lice infestation:
This is a secondary prevention intervention aimed at addressing an already identified problem—in this case, a lice infestation. By informing parents, the nurse is helping to manage and control the spread of lice among students, which is a direct response to an identified health issue.
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