Which nursing diagnosis takes priority for a 15-year-old child with third-degree burns of the hands, face, and chest?
Disturbed Body Image related to physical appearance
Ineffective Airway Clearance related to edema
Risk for Infection related to epidermal damage
Impaired Urinary Elimination related to fluid loss
The Correct Answer is B
Choice A reason: While a disturbed body image can impact psychological well-being, it is not the immediate priority in the acute phase of burn management.
Choice B reason: Ineffective airway clearance due to edema from burns to the face and chest poses an immediate threat to life, requiring urgent attention to maintain breathing.
Choice C reason: The risk for infection is a significant concern due to epidermal damage; however, it follows airway management in terms of immediate priorities.
Choice D reason: Impaired urinary elimination may occur due to fluid shifts after burns, but ensuring effective airway clearance is the most critical initial step in care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Palliative care is often beneficial for children with serious illnesses such as leukemia, where the focus is on improving quality of life and providing relief from the symptoms and stress of the illness.
Choice B reason: While a broken arm is painful, it is typically not a condition that requires palliative care, as it does not usually involve a life-threatening or chronic illness.
Choice C reason: Recurrent asthma exacerbations can be serious, but palliative care is generally reserved for more severe chronic conditions that are not well-controlled.
Choice D reason: Third-degree burns are severe and require specialized care, but palliative care is most beneficial for conditions that are chronic and life-limiting, which may not be the case with localized burn injuries.
Correct Answer is D
Explanation
Choice A reason: Keeping suction equipment at bedside is important to maintain airway patency and prevent aspiration.
Choice B reason: Positioning the child upright for feedings can help prevent aspiration and is a recommended practice.
Choice C reason: Feeding slowly using specialized feeding bottles can help the infant feed effectively and safely.
Choice D reason: This is the correct choice. Breastfeeding is often possible with the use of special techniques and should not be discouraged unless specifically contraindicated.
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