A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?
Refer the child to social work for early intervention.
Educate the parents on the developmental delays their child is diagnosed with.
Provide the parents with pamphlets for support groups for children with developmental delays.
Discuss the assessment findings with the primary care provider.
The Correct Answer is D
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.
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Correct Answer is A
Explanation
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.
Correct Answer is A
Explanation
Choice A rationale
Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.
Choice B rationale
This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.
Choice C rationale
Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.
Choice D rationale
Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.