The nurse is caring for a 2-month-old child who suffered burns on his face due to abuse. What is the nurse’s immediate priority concern when caring for this patient?
Managing the airway.
Monitoring renal function.
Restoring fluid volume.
Assessing for shock.
The Correct Answer is A
Choice A rationale
The immediate priority when caring for a patient with facial burns, especially a 2-month-old child, is managing the airway. Burns can cause swelling and compromise the airway, leading to respiratory distress. Therefore, ensuring a patent airway is crucial in these cases.
Choice B rationale
While monitoring renal function is important in burn patients due to the risk of acute kidney injury from decreased perfusion, it is not the immediate priority.
Choice C rationale
Restoring fluid volume is a critical part of burn management. However, it is not the immediate concern when the airway could be compromised.
Choice D rationale
Assessing for shock is important in burn patients due to the risk of hypovolemic shock from fluid loss. However, airway management takes precedence.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
An eight-year-old child who weighs 60 pounds, rides a bike without training wheels, and is an active swimmer is showing appropriate developmental milestones for their age. Riding a bike and swimming are complex activities that require good motor coordination and balance. These activities also indicate that the child is physically active, which is beneficial for overall health.
Choice B rationale
A three-year-old child who weighs 28 pounds, requires help with feeding, dislikes most foods, and refuses to drink milk may be showing signs of a feeding disorder or picky eating, which can lead to nutritional deficiencies and impact growth and development. This child requires further evaluation to determine the cause of these feeding difficulties and to develop a plan to address them.
Choice C rationale
A six-month-old who weighs 16 pounds, continues to breastfeed, has started solid foods, and is beginning to crawl is showing appropriate developmental milestones for their age. The World Health Organization recommends exclusive breastfeeding for the first six months of life, followed by the introduction of appropriate complementary foods. Crawling is also a typical developmental milestone that usually appears between 6 and 10 months of age.
Choice D rationale
A four-year-old child who weighs 40 pounds, eats from the same plate every meal, and is occasionally a picky eater is within normal behavior for their age. It’s common for
preschoolers to have food preferences and to want routines, such as using the same plate. Picky eating is also a common behavior at this age and usually isn’t a cause for concern unless it leads to nutritional deficiencies or other health problems.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Pain management is crucial after a tonsillectomy. Pain can prevent children from eating or drinking, leading to dehydration. Therefore, ensuring that the child’s pain is well managed is an important part of post-operative care.
Choice B rationale
Mild ear pain or bad breath after surgery can be signs of complications such as infection. Therefore, parents should be instructed to report these symptoms if they occur.
Choice C rationale
After a tonsillectomy, the throat is often sore and swollen. Eating soft foods can help prevent further irritation or injury to the throat. Crunchy foods could scratch the healing throat and cause discomfort.
Choice D rationale
While it’s true that scabs will form on the tonsils as they heal, it’s important to monitor them. If a scab dislodges too early, it can cause bleeding. Therefore, this statement is not entirely accurate and should not be included in the discharge instructions.
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