A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor.

Which potential complication should the nurse monitor closely?

A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct

This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.

The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.

B - The abrasions on the boy's leg and hand have healed.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.

C - The mother describes what she did after her child got injured.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.

D - The boy lacks coordination when answering the nurse's questions.

This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.

The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.

Choice A rationale:

While it’s important to monitor for any adverse reactions following a vaccination, not all fevers are serious. Mild fever can be a common side effect of vaccinations and is usually not a cause for concern. However, if the child develops a high fever, or if the fever is accompanied by other severe symptoms such as difficulty breathing or extreme lethargy, it should be reported to a healthcare provider immediately.

Choice B rationale:

There is no need to keep the child home from daycare following the Hib vaccine unless the child is feeling unwell or has other symptoms that warrant staying home. The Hib vaccine is not a live vaccine, so the child cannot transmit the vaccine strain to others.

Choice C rationale:

Applying a cool pack to the injection site can help reduce discomfort or swelling that may occur after the vaccination. This is a safe and effective method for managing minor side effects of vaccinations.

Choice D rationale:

Aspirin should not be given to children due to the risk of Reye’s syndrome, a rare but serious condition that can affect the liver and brain. Instead, over-the-counter pain relievers such as acetaminophen or ibuprofen can be used to help manage any pain or fever following the vaccination, if approved by a healthcare provider. Always follow the dosing instructions on the package and consult with a healthcare provider if unsure.