A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
An infant who has pertussis and is receiving oxygen via nasal cannula.
A school-age child who has diabetes mellitus and requires blood glucose monitoring.
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
A toddler who has both arms in casts and needs to be fed his breakfast.
The Correct Answer is A
Choice A reason: An infant who has pertussis and is receiving oxygen via nasal cannula:
Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.
Choice B reason: A school-age child who has diabetes mellitus and requires blood glucose monitoring:
While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.
Choice C reason: An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions:
Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.
Choice D reason: A toddler who has both arms in casts and needs to be fed his breakfast:
While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.
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Correct Answer is D
Explanation
Choice A reason:
Family history of cardiac disease is a non-modifiable risk factor. This means it cannot be changed or controlled through lifestyle or behavioral modifications. A family history of heart disease increases an individual’s risk, but it is not something that can be altered.
Choice B reason:
Increasing age is another non-modifiable risk factor. As people age, their risk for cardiovascular disease naturally increases. This is due to the cumulative effects of aging on the cardiovascular system, which cannot be changed.
Choice C reason:
The diagnosis of diabetes mellitus is a complex risk factor. While the presence of diabetes itself is not modifiable, the management of diabetes through lifestyle changes, medication, and diet can significantly reduce cardiovascular risk. However, the condition itself remains a non-modifiable risk factor.
Choice D reason:
Cigarette smoking is a modifiable risk factor. This means that individuals can reduce their risk of cardiovascular disease by quitting smoking. Smoking cessation has been shown to significantly lower the risk of heart disease and improve overall cardiovascular health.
Correct Answer is A
Explanation
Choice A reason: WBC count:
An elevated white blood cell (WBC) count is a common indicator of infection. The body produces more white blood cells to fight off infections, making this a key marker for identifying infections in patients with pressure ulcers. Monitoring WBC count helps in assessing the presence and severity of an infection, guiding appropriate treatment.
Choice B reason: BUN:
Blood urea nitrogen (BUN) levels are used to assess kidney function and hydration status. Elevated BUN levels can indicate dehydration or kidney dysfunction but are not specific indicators of infection. While important for overall health assessment, BUN is not directly related to detecting infections in pressure ulcers.
Choice C reason: Potassium:
Potassium levels are crucial for maintaining normal cellular function, particularly in the heart and muscles. Abnormal potassium levels can indicate issues such as kidney dysfunction or electrolyte imbalances but do not specifically indicate infection. Monitoring potassium is important for overall health but not for diagnosing infections in pressure ulcers.