How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.


    • Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

    Naxlex Comprehensive Predictor Exams

    Free Nursing Study Resources

    Related Questions

    Correct Answer is A

    Explanation

    A. Initiate isotonic fluids with 20 mEq/L potassium chloride. The priority in treating acute gastroenteritis in a toddler is to manage dehydration, which is often severe due to fluid loss from vomiting and diarrhea. Isotonic fluids with electrolytes like potassium chloride help to restore fluid balance and prevent complications like electrolyte imbalances. This is the most urgent action to stabilize the child's condition.
    B. Request evaluation of the toddler's serum electrolytes. While important, this can be done after fluid resuscitation has begun to assess the severity of electrolyte imbalances.
    C. Determine if the toddler is voiding. Important for assessing renal function, but not the first priority in acute gastroenteritis.
    D. Collect a stool sample from the toddler. Useful for identifying the causative organism but not as urgent as fluid resuscitation.

    Correct Answer is D

    Explanation

    A. Hypertension: Hypertension is not typically associated with nephrotic syndrome unless there are underlying kidney complications.
    B. Polyuria: Polyuria (increased urine output) is not typically seen in nephrotic syndrome, which is characterized by proteinuria and edema.
    C. Orange-tinged urine: Orange-tinged urine suggests the presence of blood or bilirubin, which is not typically associated with nephrotic syndrome.
    D. Periorbital edema: Periorbital edema (swelling around the eyes) is a common manifestation of nephrotic syndrome due to fluid retention.

    Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

    Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

    Register