A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child?
a. Pain resulting from tissue trauma
b. High risk for impaired skin integrity resulting from immobility
c. Altered growth and development related to separation from family
d. Altered urinary elimination related to immobility and traction
ANS: A
Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.
You might also like to view...
The nurse is preparing to provide care for a client with a C4 spinal cord injury. What should be the priority of care for this client?
1. Taking a shower 2. Maintaining the airway 3. Making an unoccupied bed 4. Using a manual wheelchair
A patient, with chronic renal failure and a blood pressure of 158/98 mm Hg, refuses to take medication for the blood pressure. If left untreated, the nurse realizes that which of the following can occur in the patient?
1. heart failure 2. pericarditis 3. friction rub 4. pneumonia
Evidence-based practice is often considered the same as ‘doing or participating in research'. What does this tell us about the importance of using research to inform evidence-based practice?
What will be an ideal response?
An 80-year-old patient asks a primary care NP about OTC antacids for occasional heartburn. The NP notes that the patient has a normal complete blood count and normal electrolytes and a slight elevation in creatinine levels. The NP should recommend:
a. calcium carbonate (Tums). b. aluminum hydroxide (Amphojel). c. sodium bicarbonate (Alka-Seltzer). d. magnesium hydroxide (Milk of Magnesia).