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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. Give the child 1⁄2 cup of orange juice to drink. These symptoms indicate hypoglycemia, a common early complication of diabetes treatment. Orange juice contains quick-acting sugars that can rapidly raise blood glucose levels and alleviate symptoms. This is the immediate action to manage the child's symptoms.
    B. Call the dietary department and ask that the lunch tray be delivered early. Delayed action compared to treating the immediate hypoglycemia.
    C. Contact the physician. While eventually necessary, immediate treatment of hypoglycemia takes precedence.
    D. Obtain a blood glucose reading. Important to confirm hypoglycemia but not as urgent as providing immediate treatment.

    Correct Answer is D

    Explanation

    A. Maintain a saline-lock.Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
    B. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
    C. A no-salt-added diet is important to help manage fluid retention and hypertension, which are common in acute glomerulonephritis. However, while important, it does not take immediate priority over assessing the child's fluid status.
    D. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.

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