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 C

Explanation

The correct answer is: c. In an emergency, a court order can be obtained for the patient to receive blood transfusions.

Choice A: The patient can only receive blood that has been donated by family members.

Jehovah’s Witnesses refuse blood transfusions, including those from family members, due to their religious beliefs. They believe that both the Old and New Testaments command them to abstain from blood (Genesis 9:4; Leviticus 17:10; Deuteronomy 12:23; Acts 15:28, 29). Therefore, this option is incorrect.

Choice B: Under no circumstances will the patient receive blood products.

While Jehovah’s Witnesses generally refuse blood transfusions, there are exceptional circumstances where medical professionals can seek a court order to administer blood transfusions, especially in life-threatening situations involving minors. Thus, this statement is not entirely accurate.

Choice C: In an emergency, a court order can be obtained for the patient to receive blood transfusions.

In life-threatening emergencies, especially involving minors, courts can intervene and issue orders to administer necessary medical treatments, including blood transfusions, despite parental objections based on religious beliefs. This ensures the child’s right to life and health is protected. Therefore, this is the correct answer.

Choice D: The patient can receive volume expanders.

Volume expanders can be used to increase blood volume and maintain circulation, but they do not carry oxygen or replace lost blood cells. While they are an option for managing blood loss, they are not a substitute for blood transfusions in severe cases of anemia or blood loss, which are common in leukemia patients. Thus, this option is not entirely correct.

A. "The father has the trait, but the mother doesn’t." B. "The mother has the trait, but the father doesn’t." C. "Both the mother and the father have the sickle cell trait." D. "The mother has sickle cell disease, but the father doesn't have the disease or the trait."

Correct Answer is C

Explanation

Choice A reason: This option is incorrect because sickle cell disease is an inherited condition, and one parent having the trait is not sufficient for a child to have the disease.
Choice B reason: This option is also incorrect for the same reason as choice A; both parents must carry the trait for the child to have a chance of inheriting the disease.
Choice C reason: This is the correct choice. Sickle cell disease is inherited when both parents carry the sickle cell trait, giving their child a 25% chance of having the disease.
Choice D reason: This option is incorrect because if only one parent has sickle cell disease and the other has neither the disease nor the trait, the child cannot have sickle cell disease.

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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

A four-year-old patient has been diagnosed with leukemia. The patient's parents, who follow the Jehovah's Witness faith, inform the physician that they will not approve any type of blood transfusions. The pediatric nurse is aware that:

Correct Answer is C

Explanation

A child is diagnosed with sickle cell disease. The parents are unsure how their child contracted the disease. Which explanation by the nurse is the most appropriate?

Correct Answer is C

Explanation

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