Which of the following is a priority nursing diagnosis for the ...

[captainjonesify]

Which of the following is a priority nursing diagnosis for the child with idiopathic thrombocytopenic purpura (ITP)?
 
  1. Ineffective breathing pattern
  2. Nausea
  3. Fluid-volume deficit
  4. Risk for injury

Question 2

Twenty-four hours after being transferred from the pediatric intensive care unit to the regular pediatrics floor, the seven-year-old child is asked about his experience in the PICU.
 
  The child says he was not in the PICU but came directly to the floor from the ambulance ride. The nurse recognizes this is a coping behavior for the child known as: 1. Repression.
  2. Regression.
  3. Amnesia.
  4. Developmental delay.

[dreamfighter72]

Answer to Question 1

4
Rationale 1: Although in an advanced state TP can impact breathing, it does not usually cause ineffective breathing patterns.
Rationale 2: Nausea is not a symptom of ITP.
Rationale 3: Fluid-volume deficits are not likely to occur with ITP.
Rationale 4: ITP is the most common bleeding disorder in children, so risk for injury and subsequent bleeding is the priority nursing diagnosis.
Global

Answer to Question 2

1
Rationale 1: Repression is the involuntary forgetting of an experience due to the stress of the situation.
Rationale 2: Regression is a return to earlier behaviors, such as loss of continence or asking for a bottle in a toddler.
Rationale 3: Amnesia is the loss of memory that can result from a head injury. There is no indication of a head injury occurring in this child.
Rationale 4: Developmental delay refers to a child whose behavior is not appropriate for the chronologic age of the child.
Global Rationale: