A nurse is providing care for a group of hospitalized school-aged children. Which of the following clients should the nurse prioritize for further assessment and interventions?
A child who is visibly anxious and withdrawn while in the hospital
A child whose vital signs are stable whose parent expresses concerns about the disruption to the child's routine
A child who is experiencing stomach pain without an apparent cause
A child who is exhibiting aggressive behavior towards peers and healthcare providers
The Correct Answer is D
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.
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Correct Answer is C
Explanation
A. Solitary play is more characteristic of earlier stages of development, such as infancy and early childhood. School-age children benefit more from social interactions.
B. While academic achievements are important, focusing solely on individual success does not support the social skills that are essential for this developmental stage.
C. Encouraging participation in team sports promotes social interaction, teamwork, and a sense of belonging, which are crucial for developing competence and self-esteem during this stage.
D. Promoting dependence on parents goes against the developmental task of this age group, which is to foster independence and decision-making skills.
Correct Answer is ["A","B","D","E"]
Explanation
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.