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 C
Explanation
Choice A reason: Using the palm of the hand, feel for lumps using a circular motion:
This instruction is incorrect. The correct method for a breast self-exam involves using the pads of the three middle fingers, not the palm of the hand. The fingers should move in a circular motion to feel for lumps or abnormalities.
Choice B reason: Expect some breast dimpling or discharge with age:
This is misleading and potentially harmful advice. While some changes in the breast can occur with age, dimpling or discharge can also be signs of breast cancer and should be reported to a healthcare provider immediately.
Choice C reason: Breasts can be examined in the shower with soapy hands:
This is correct. Examining the breasts in the shower with soapy hands can make it easier to feel for lumps or changes. The soapy water helps the fingers glide smoothly over the skin, making it easier to detect any abnormalities.
Choice D reason: For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation:
This instruction is incorrect. The best time to perform a breast self-exam is a few days after the menstrual period ends, when the breasts are least likely to be swollen or tender.
Correct Answer is D
Explanation
Choice A reason: Chicken broth:
Chicken broth is part of a clear liquid diet, which is typically recommended immediately after surgery to ensure the digestive system is not overburdened. While nutritious, it does not meet the criteria for a full liquid diet, which includes more substantial liquids.
Choice B reason: Flavored gelatin:
Flavored gelatin is also a component of a clear liquid diet. It is easy to digest and provides some hydration and minimal calories. However, it does not provide the nutritional value needed for a full liquid diet.
Choice C reason: Cranberry juice:
Cranberry juice is another item that fits within a clear liquid diet. It is hydrating and provides some vitamins but lacks the protein and calories necessary for a full liquid diet.
Choice D reason: Skim milk:
Skim milk is appropriate for a full liquid diet. It provides essential nutrients, including protein, calcium, and vitamins, which are necessary for recovery after surgery4. Full liquid diets are designed to be more nutritious than clear liquid diets and include items like milk, cream soups, and smooth dairy products.