A nurse is preparing a plan of care for a child with a primary immunodeficiency. Which nursing diagnosis would the nurse most likely identify as the priority?
A) Imbalanced nutrition, less than body requirements related to poor appetite
B) Ineffective protection related to impaired humoral defenses
C) Acute pain related to inflammatory processes
D) Risk for delayed growth and development related to chronic illness
B
Feedback:
The child with a primary immunodeficiency lacks the necessary immune responses that provide protection from infection. Therefore, the priority nursing diagnosis would be ineffective protection. Imbalanced nutrition and risk for delayed growth and development may be appropriate, but these would not be the priority. Acute pain would be more appropriate for a child with juvenile idiopathic arthritis.
You might also like to view...
____________________ is the most common cause of blindness in African Americans
Fill in the blank(s) with correct word
The nurse assesses an unmet need in a hospitalized child who clings to his mother as she is about to leave. As described by Maslow, the basic needs that may be unmet in this case are __________ and ___________
ANS:
In teaching a 16-year-old adolescent who was recently diagnosed with systemic lupus erythematosus (SLE), what statements should the nurse include? (Select all that apply.)
a. "You should use a moisturizer with a sun protection factor (SPF) of 30." b. "You should avoid pregnancy because this can cause a flare-up." c. "You should not receive any immunizations in the future." d. "You may need to be on a low-protein, high-carbohydrate diet." e. "You should expect to lose weight while taking steroids." f. "You may need to modify your daily recreational activities."
A 4-year-old has been sexually abused. As you watch her play with anatomically correct dolls, she inserts the male doll's penis into the female doll's mouth. What is your best response to this action?
A) "Be careful; you'll hurt the doll that way." B) "Are you playing a game from television?" C) "What are the dolls doing?" D) "Nice dolls don't do that. Why are you playing that way?"