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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 should not take my regular insulin when I am sick." Regular insulin should not be withheld during illness, as blood glucose levels can increase during times of stress or infection. This statement indicates the child needs further education on managing diabetes during illness.
    B. "I will rotate injections sites within my abdominal area." Rotating injection sites within a specific area helps to prevent lipodystrophy and ensures consistent absorption of insulin. This statement shows appropriate understanding.
    C. "I will test my blood sugar before meals and at bedtime." Frequent monitoring of blood glucose is essential in managing type 1 diabetes. This statement indicates correct knowledge of monitoring practices.
    D. "I should eat a snack before I play soccer." Eating a snack before physical activity helps to prevent hypoglycemia. This statement indicates a proper understanding of diabetes management related to exercise.

    Correct Answer is C

    Explanation

    A. Take the prescribed insulin 30 minutes before practice or game time rather than in the morning. Insulin timing should generally be consistent with meal times to match insulin action with food intake. Adjusting timing without medical advice can lead to imbalanced blood sugar levels.
    B. Eat half the amount of food normally eaten at lunchtime. Eating less food than usual can lead to hypoglycemia during prolonged physical activity and is not recommended.
    C. Eat six graham crackers or drink a cup of orange juice before practice or game time. This action helps to prevent hypoglycemia during physical activity by providing quick-acting carbohydrates that can be readily absorbed and utilized by the body.
    D. Take two times the amount of prescribed insulin on practice and game days. Doubling insulin doses without medical supervision can lead to hypoglycemia and is not appropriate for managing blood sugar during physical activity.

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