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A nurse is assisting in the care of a toddler.

Exhibits

A nurse is assisting in the care of a client. Complete the following sentence by using the list of options.

The nurse should first address the child's

followed by the child's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

    Immediate priority: The child is febrile (38.9°C) with tachycardia. Fever and low Hgb and platelets suggest possible serious underlying hematologic disorder (e.g., leukemia, bone marrow suppression). Infection is life-threatening in this context. So temperature (fever) should be addressed first. Next concern: The lab values (low Hgb, Hct, platelets) show significant hematologic abnormalities that explain the fatigue, bruising, and petechiae and will guide further treatment (possible transfusion, infection risk management). Incorrect answers:
  • Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
  • Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
  • Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.
  • Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.
  • Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.
  • Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.


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    Related Questions

    Correct Answer is A

    Explanation

    A. "I will keep my baby in an upright position after feeding." Keeping the infant upright after feedings helps reduce reflux by utilizing gravity to keep the stomach contents from coming back up into the esophagus.
    B. "I will have to feed my baby formula, rather than breast milk." Breast milk is actually preferred for infants with reflux as it is digested more quickly than formula, which may reduce reflux episodes.
    C. "My baby's formula can be thickened with oatmeal." While thickening feeds can help in some cases, it's generally done with rice cereal under the guidance of a healthcare provider. Oatmeal is not typically recommended for thickening formula for young infants.
    D. "I should move my baby into a side-lying position during sleep." Side-lying position is not recommended for sleep due to the risk of sudden infant death syndrome (SIDS). The baby should be placed on their back to sleep.

    Correct Answer is A

    Explanation

    A. "Encourage your child to avoid sharing hats with other children." Lice are primarily transmitted through direct head-to-head contact, not by sharing hats or other items.
    B. "Lice can jump from one child to another." Lice cannot jump; they crawl from one person to another during direct contact.
    C. "Lice do not survive away from the host." Lice can survive away from a host for a limited period (usually less than a day) but not for extended periods.
    D. "Washing your child's hair daily will prevent lice." While good hygiene is important, washing hair daily does not necessarily prevent lice infestations.

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