Which observation is the priority to consider when planning care for a 7-year-old hospitalized client? This client:.

is intolerant of strangers.

is becoming increasingly modest.

may have imaginary companions.

prefers that others make decisions.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Priority consideration should be given to the child's intolerance of strangers, as it directly impacts the child's safety and comfort in the hospital environment.

Choice B rationale:

Increasing modesty is a normal developmental aspect, but it doesn't take precedence over safety concerns or the immediate hospital care needs.

Choice C rationale:

Having imaginary companions is a common behavior in children and is not an immediate priority in planning care.

Choice D rationale:

While the child's preference for others making decisions might be a consideration, it is not as urgent as addressing the child's intolerance of strangers, which can affect the child's emotional well-being and cooperation during hospitalization.

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Correct Answer is D

Explanation

Choice A rationale:

Ketonuria is the presence of ketones in urine and is not directly associated with vaso-occlusive crisis in sickle cell anemia. This crisis typically involves pain and ischemia in various body parts.

Choice B rationale:

Diplopia refers to double vision and is not a typical symptom of vaso-occlusive crisis. Pain, not vision changes, is the primary concern in this scenario.

Choice C rationale:

Severe abdominal pain can be a symptom of vaso-occlusive crisis in sickle cell anemia, but the patient's complaint of left elbow pain would not directly correlate with this choice.

Choice D rationale:

Hyperactive patellar reflex is the correct answer. During vaso-occlusive crisis, the body's response to pain can lead to increased muscle tone and reflexes, including hyperactive deep tendon reflexes like the patellar reflex. This is an indicator of neurologic involvement in the crisis. Remember that these rationales are intended to provide a concise understanding of the correct answers based on the information provided in the questions. Always refer to medical literature and consult with healthcare professionals for comprehensive and accurate information.

A. "We will return to the hospital if my child spits up blood.". B. "I'll give my child cherry gelatin since that is her favorite.". C. "We will return to the hospital if my child develops difficulty breathing.". D. "I'll have my child rinse her mouth frequently with water to prevent a bad breath odor.".

Correct Answer is B

Explanation

Choice A rationale:

Returning to the hospital if the child spits up blood is a correct response as it indicates the recognition of potential postoperative bleeding.

Choice B rationale:

Giving the child cherry gelatin, even though it's the child's favorite, might not be appropriate after a tonsillectomy/adenoidectomy, as certain foods can irritate the healing throat.

Choice C rationale:

Returning to the hospital if the child develops difficulty breathing is a necessary step to address any respiratory distress.

Choice D rationale:

Having the child rinse her mouth frequently with water to prevent a bad breath odor is a suitable suggestion to maintain oral hygiene and comfort after surgery. In all three scenarios, the rationale for the correct answers revolves around patient safety, comfort, and appropriate post-operative care. The incorrect choices in each question either introduce potential complications, misunderstandings, or actions that might compromise the patient's well-being.

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Which observation is the priority to consider when planning care for a 7-year-old hospitalized client? This client:.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An 11-year-old patient with sickle cell anemia is admitted to the hospital with vaso-occlusive crisis. He is experiencing pain in his left elbow. The nurse needs to monitor the patient for which symptom?

Correct Answer is D

Explanation

The nurse is providing discharge instructions to the parent of a patient who had a tonsillectomy/adenoidectomy. Which statement would indicate that the parent needs further teaching?

Correct Answer is B

Explanation

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