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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing pedal pulses is important, but it does not provide complete information about the circulatory status of the infant.
Choice B reason: This is the correct choice. Discrepancies in pulse strength between the upper and lower extremities may indicate a cardiovascular problem such as coarctation of the aorta, which can be further evaluated by comparing blood pressures in all four extremities.
Choice C reason: Lower extremity reflexes are not directly related to the strength of pulses.
Choice D reason: Hemoglobin and hematocrit values are important but would not be the next step in assessing the significance of the difference in pulse strength.
Correct Answer is D
Explanation
Choice A reason: Limiting the use of mobility equipment is not recommended as it can lead to decreased mobility and increased joint stiffness.
Choice B reason: Massaging inflamed joints is not recommended as it can increase pain and inflammation.
Choice C reason: Substituting natural fruit juices for carbonated drinks is a healthy choice but does not directly address the management of gouty arthritis.
Choice D reason: This is the correct choice. Periodic liver function studies are important when taking medications like colchicine and indomethacin, which can affect liver function. Monitoring liver function helps ensure the safety of the medication regimen.
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