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: This is the correct choice. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination and a risk of dehydration and hypernatremia (high sodium levels).
Choice B reason: Hyperglycemia is associated with diabetes mellitus, not diabetes insipidus.
Choice C reason: Hypoglycemia (low blood sugar) is not a typical finding in diabetes insipidus.
Choice D reason: Hypercalcemia (high calcium levels) is not directly related to diabetes insipidus.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Congestive heart failure can occur in chronic renal failure due to fluid overload and the inability of the kidneys to manage fluid balance.
Choice B reason: Metabolic alkalosis is not typically a major complication of chronic renal failure; metabolic acidosis is more common due to the accumulation of acids in the body.
Choice C reason: Excessive excretion of blood urea nitrogen is not a complication; rather, in renal failure, the kidneys cannot excrete urea nitrogen effectively.
Choice D reason: Hypokalemia (low potassium) can occur, but it is not as major a complication as congestive heart failure in the context of chronic renal failure.
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