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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 D

    Explanation

    A. "I'm tired and want to take a nap." Common in sick children and not necessarily concerning in this context.
    B. "I am scared and I want to go home." Emotional response, typical in children facing surgery.
    C. "I am hungry and thirsty." Normal sensations and not indicative of the severity of the condition.
    D. "My belly doesn't hurt anymore." This statement suggests potential rupture or perforation of the appendix, which can lead to peritonitis and is a surgical emergency. A sudden relief of pain can indicate a worsening condition rather than improvement.

    Correct Answer is B

    Explanation

    A. "When patches are present, it indicates that your infant has a systemic infection." Seborrheic dermatitis is a benign, non-infectious condition and does not indicate systemic infection.
    B. "You can use petrolatum to help soften and remove patches from your infant's scalp. Petrolatum can help soften and loosen scales in seborrheic dermatitis, making them easier to remove gently. This can help manage the condition effectively.
    C. "You should avoid washing your infant's hair while patches are present on the scalp." Gentle washing with a mild shampoo can help manage seborrheic dermatitis. Avoiding washing altogether is not necessary unless advised by a healthcare provider.
    D. "When patches are present, you should keep your infant away from others." Seborrheic dermatitis is not contagious, so there is no need to keep the infant away from others.

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