What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

Risk for Altered Tissue Perfusion

Impaired Physical Mobility

Risk for Altered Nutrition: Less than Body Requirements

Risk for Fluid Imbalance

Answer and Explanation

The Correct Answer is A

Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.

Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.

Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.

Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.

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Correct Answer is B

Explanation

Choice A reason: This statement is incorrect and could potentially increase feelings of guilt, as a lack of prenatal care is not a known cause of autism.

Choice B reason: This statement is accurate and can help alleviate guilt by explaining that autism is not caused by something the parents did or did not do.

Choice C reason: While it's true that parents without genetic testing could not have known, this statement does not address the feelings of guilt regarding causation.

Choice D reason: This statement is misleading because autism is not considered rare, and siblings can have an increased risk of autism spectrum disorders. It does not provide accurate information or address the parents' feelings of guilt.

A. High-pitched cry. B. Decreased lower extremity movement. C. Excessive wet diapers. D. Bulging fontanel when crying.

Correct Answer is D

Explanation

Choice A reason: While a high-pitched cry can be a sign of distress, it is not a specific indicator of increased intracranial pressure.
Choice B reason: Decreased movement in the lower extremities can indicate a neurological issue but is not a specific sign of increased intracranial pressure.
Choice C reason: Excessive wet diapers are not related to intracranial pressure.
Choice D reason: This is the correct choice. A bulging fontanel, especially when crying, can indicate increased intracranial pressure in an infant. It is important to monitor for other signs and symptoms as well.

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What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?

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Naxlex Comprehensive Predictor Exams

Which statement by the nurse would best help alleviate parental guilt about their child, George, who has been recently diagnosed with autism?

Correct Answer is B

Explanation

What notable sign most likely indicates increased intracranial pressure in an infant?

Correct Answer is D

Explanation

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