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.

Answer and Explanation

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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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.

A. A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93%. B. A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93%. C. A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93%. D. A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93%.

Correct Answer is A

Explanation

Choice A rationale

A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93% is showing signs of severe respiratory distress. The weak cry and pale complexion suggest poor oxygenation and possible hypoxia. Decreased breath sounds and retractions indicate the child is struggling to breathe. An oxygen saturation of 93% is below the normal range for infants, further indicating respiratory distress. This child should be prioritized for treatment.

Choice B rationale

A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress, but not as severe as Choice A12. The ability to speak in full sentences and having a pink complexion suggest that the child is getting

enough oxygen. However, bilateral wheezing indicates some airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for children this age.

Choice C rationale

A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93% is also showing signs of respiratory distress. Speaking in short phrases and sitting upright are signs that the teenager is working harder to breathe. Wheezing indicates airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for teenagers.

Choice D rationale

A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress. Being quiet and pale can indicate poor oxygenation. Bilateral wheezing suggests airway obstruction. An oxygen saturation of 93% is below the normal range for children this age. However, this child’s symptoms are not as severe as those of the 12-month-old in Choice A.

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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?

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