A nurse in an emergency department (ED) is assisting in the care of a 4- year-old child.
Complete the diagram by dragging from the choices below to specify what condition the child is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to check the child's progress.
The Correct Answer is []
Condition:
Pyelonephritis: The presence of fever, frequent and painful urination, and costovertebral angle tenderness, along with the urinalysis findings (cloudy urine, leukocyte esterase, nitrites, WBCs) and elevated WBC count suggest an upper urinary tract infection, likely pyelonephritis.
Actions to Take:
Request prescription for antibiotics: Pyelonephritis is a bacterial infection that requires antibiotic treatment to prevent complications and resolve the infection.
Encourage increased fluid intake: This helps to flush bacteria from the urinary tract, reducing the concentration of bacteria in the urine and helping to relieve symptoms.
Parameters to Monitor:
Child’s report of urgency: This can help assess if the infection is affecting the lower urinary tract as well and track the effectiveness of treatment.
Urine odor: Foul-smelling urine can indicate ongoing infection or bacterial presence and can be an indicator of the effectiveness of the treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Polyuria is not typically associated with sepsis; it may be seen in other conditions such as diabetes. In sepsis, urine output is often decreased due to impaired kidney function and shock.
B. Disorientation is a sign of sepsis, indicating that the infection may have spread to the bloodstream and is affecting the central nervous system. Altered mental status is a critical indicator of severe infection.
C. Hyperactive bowel sounds are not associated with sepsis. In sepsis, bowel sounds may actually be decreased due to decreased perfusion to the gastrointestinal tract.
D. Hypoglycemia can occur in sepsis, but it is not as specific an indicator as disorientation. Monitoring blood glucose levels is important, but disorientation provides a clearer sign of systemic infection.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}
Explanation
Medication (Ceftriaxone): Given the infant's history of amoxicillin allergy, there is a potential cross-reactivity concern with cephalosporins like ceftriaxone. It's crucial to clarify the allergy details and assess for any potential allergic reactions before administering.
Finding (Allergy): The infant has a documented allergy to amoxicillin, which raises concerns about potential cross-reactivity with cephalosporins, including ceftriaxone. Clarifying the allergy details ensures safe administration and prevents adverse reactions.
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