A nurse in the provider's office is assisting with the care of a child.
Upon review of the child's electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions? Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developingThe Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Increased seizure activity
- Finding: Phenytoin level
The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.
Pneumonia
- Finding: Cough
A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.
Liver failure
- Finding: Skin rash
Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.
Steven-Johnson syndrome
- Finding: Liver enzymes
Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.
Pneumothorax
- Finding: Lung sounds
A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Answer: B. "I'll take this medication with a full glass of milk."
A. "I'll take this medication at least an hour before I eat a meal."
This statement indicates correct understanding. Tetracycline should ideally be taken on an empty stomach, which means taking it at least one hour before or two hours after meals to maximize absorption and effectiveness.
B. "I'll take this medication with a full glass of milk."
This statement indicates a need for further education. Tetracycline should not be taken with dairy products, including milk, because calcium in dairy can bind to the antibiotic and significantly reduce its absorption, making the medication less effective.
C. "I'll take this medication with a full glass of water on an empty stomach."
This statement demonstrates proper understanding. Tetracycline should be taken with a full glass of water and on an empty stomach to ensure optimal absorption and reduce the risk of gastrointestinal irritation.
D. "I'll stay out of direct sunlight while taking this medication."
This statement reflects correct knowledge about the medication. Tetracycline can increase sensitivity to sunlight (photosensitivity), so it is advisable for the client to avoid prolonged exposure to direct sunlight and use sunscreen to protect their skin.
Correct Answer is B
Explanation
A. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
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