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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.

A child who is visibly anxious and withdrawn while in the hospital

B.

A child whose vital signs are stable whose parent expresses concerns about the disruption to the child's routine

C.

A child who is experiencing stomach pain without an apparent cause

D.

A child who is exhibiting aggressive behavior towards peers and healthcare providers

Answer and Explanation

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. Secondary prevention involves early detection and prompt intervention in health issues that have already occurred; providing education about stress does not fall under this category.

B. Suicide prevention is a specific aspect of mental health care and is not directly related to general stress education.

C. Primary prevention aims to prevent the onset of health issues and promote health and well-being, making the education on stress and its effects a form of primary prevention.

D. Tertiary prevention focuses on rehabilitation and management of existing diseases, which does not apply to teaching about stress effects.

Correct Answer is B

Explanation

A. Supraventricular tachycardia (SVT) typically has identifiable P waves; the absence of P waves suggests a different condition.

B. Atrial fibrillation is characterized by an irregular rhythm, inability to identify P waves, and varying intervals. This interpretation aligns with the client's ECG findings.

C. Sinus bradycardia would show identifiable P waves and a regular rhythm with a heart rate less than 60 bpm, which does not match the provided information.

D. First-degree heart block would also show identifiable P waves and regularity in the rhythm with a prolonged PR interval, which is not indicated here.

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