A nurse is assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?
A toddler who has periorbital cellulitis and has an axillary temperature of 37.6° C (99.7° F)
An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10
An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding
A child who had a cast placed 4 hr ago and reports numb in the affected extremity
The Correct Answer is D
A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.
B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.
C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.
D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Use a moisture barrier on the client's skin: Applying a moisture barrier cream helps protect the skin from irritation caused by constant exposure to stool and urine. It creates a protective layer that prevents breakdown, reduces friction, and maintains skin integrity in incontinent clients.
B. Clean the client's skin with soap and hot water: Using soap and hot water can strip the skin of natural oils and cause dryness or irritation, which increases the risk of breakdown. Gentle cleansing with mild soap and lukewarm water is recommended instead to preserve skin health.
C. Massage the area around the client's coccyx: Massaging bony prominences can damage fragile tissue and capillaries in older adults, increasing the risk for pressure injuries rather than preventing them. Light touch is appropriate, but firm massage should be avoided in at-risk areas.
D. Limit the client's fluid intake: Restricting fluids can lead to dehydration, concentrated urine, and an increased risk of urinary tract infections. Adequate hydration is essential to support overall health and skin resilience, even when managing incontinence.
Correct Answer is C
Explanation
A. "I have switched from tobacco cigarettes to electronic cigarettes.": Although electronic cigarettes may reduce exposure to certain harmful chemicals found in tobacco smoke, they still pose significant health risks. This change does not reflect truly limiting risky behavior but rather substituting one form of risk for another.
B. "Sometimes I am exposed to toxic chemicals at my workplace, but not any that have harmed me.": Exposure to toxic chemicals, even without immediate harm, still represents ongoing risk. A proactive approach would involve using protective equipment or seeking safer work conditions.
C. "Two of my grandparents had diabetes, so I try to eat a healthy diet.": Actively modifying diet in response to a family health history shows a positive, preventative approach and reflects conscious efforts to limit risk-taking behaviors and promote long-term health.
D. "My job and home life are both very stressful, but I haven't been able to do anything about that.": Chronic unmanaged stress is a health risk, and acknowledging stress without taking steps to manage it indicates that the client is not effectively limiting risk behaviors.
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