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: Meningitis is an infection of the protective membranes covering the brain and spinal cord and is not typically listed as a risk factor for ADD/ADHD.

Choice B reason: A family history of ADD/ADHD is a known risk factor, as the disorder can have a genetic component.

Choice C reason: Exposure to environmental toxins, such as lead, is associated with an increased risk of developing ADD/ADHD.

Choice D reason: While maternal health issues like gestational diabetes can impact a child's development, they are not directly linked to ADD/ADHD as a risk factor in the same way as genetic or environmental factors. However, this choice is less incorrect than Choice A, as there is some evidence suggesting a potential association between gestational diabetes and developmental disorders.

A. A 7-year-old child B. A 5-month-old infant C. A 4-year-old child D. A 15-month-old toddler

Correct Answer is C

Explanation

Choice A reason: A 7-year-old child may have some difficulty with separation but is typically able to understand the reason for hospitalization better than younger children.
Choice B reason: A 5-month-old infant may show signs of distress but does not have the same understanding of separation as an older child.
Choice C reason: This is the correct choice. A 4-year-old child is at a developmental stage where separation from family can cause significant distress and difficulty.
Choice D reason: A 15-month-old toddler may experience separation anxiety, but it is generally more intense in preschool-aged children.

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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

Which of the following is NOT a risk factor for pediatric mental health disorders such as Attention Deficit Disorder (ADD)/ADHD?

Correct Answer is A

Explanation

In planning care, the nurse recognizes that which child should have the most difficulty with separation from family during hospitalization?

Correct Answer is C

Explanation

A nurse is conducting developmental assessments on several children in the day-care setting. Which two children does the nurse identify as having developmental delays?

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