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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. Hard candy can help relieve the sensation of thirst without causing fluid overload.
Choice B reason: Measuring capillary glucose is not directly related to managing thirst in SIADH.
Choice C reason: Withholding diuretics without medical advice could be harmful and is not related to managing thirst.
Choice D reason: Providing additional oral fluids may exacerbate fluid retention in SIADH and is not recommended.

A. An orogastric tube fails to pass at birth. B. The infant has a low birth weight. C. It is visually identified at the time of delivery. D. Dry mouth and nares, little to no oral secretions at delivery.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. If an orogastric tube fails to pass, it may indicate a blockage or abnormal connection, such as a tracheoesophageal fistula.
Choice B reason: Low birth weight can be associated with many conditions and is not specific to TEF.
Choice C reason: TEF is not typically visible without special imaging or procedures; it cannot be visually identified at delivery.
Choice D reason: Dry mouth and nares with little to no oral secretions could indicate other conditions and are not specific to TEF. TEF often presents with excessive oral secretions.

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Which nursing diagnosis takes priority for a 15-year-old child with third-degree burns of the hands, face, and chest?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with chronic syndrome of inappropriate anti-diuretic hormone (SIADH) reports to the nurse that they feel constantly thirsty. Which action should the nurse take?

Correct Answer is A

Explanation

What clinical manifestation in a newborn would cause a nurse to suspect the diagnosis of tracheoesophageal fistula (TEF)?

Correct Answer is A

Explanation

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