A nurse is assisting in the care of an adolescent who reports abdominal pain.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first address the client's

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followed by the client’s

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.

• Temperature: The child has a fever of 38.9°C (102°F), which is above the normal range for toddlers (36.5°C to 37.5°C or 97.7°F to 99.5°F). A high fever can indicate an ongoing infection or inflammatory process and can lead to serious complications, especially in a toddler. Addressing the fever promptly is crucial to prevent potential febrile seizures, dehydration, and other heat-related complications. Fever management is essential to improving the child's comfort and preventing the worsening of symptoms.
• 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.

ii. Follow-up Priority: Laboratory Values

Rationale:

• Laboratory values: The child’s laboratory results show abnormalities that are significant. Hemoglobin is low at 7.6 g/dL (indicating anemia), hematocrit is also low at 21%, and platelets are decreased at 110,000/mm³, which could suggest a hematologic disorder such as leukemia or a severe infection. The elevated white blood cell count further supports the presence of an infection or an inflammatory response. These lab abnormalities are critical and need to be addressed to determine the underlying cause and to plan further treatment.
• 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.

A. Test the urine for ketones. While testing for ketones can be part of illness management in diabetes, it is not as immediate an action as contacting a healthcare provider when blood glucose levels are very high.
B. Withhold insulin dose if feeling nauseous. Insulin should not be withheld due to nausea. It is important to maintain insulin to control blood glucose levels even when feeling unwell. Adjustments to insulin may be necessary based on blood glucose levels and food intake.
C. Notify the provider if blood glucose levels are over 350 mg/dL. Blood glucose levels over 350 mg/dL are concerning and may indicate the need for medical intervention to prevent complications like diabetic ketoacidosis. The healthcare provider should be notified.
D. Limit fluid intake during meal time. Adequate fluid intake is important, especially when blood glucose levels are high, to help prevent dehydration and facilitate glucose clearance. Limiting fluids is not appropriate.