A nurse is assisting with collecting data from a 10-month-old in the emergency department.

Medical History: Guardians brought the infant to the emergency room after witnessing the infant’s arms and legs shaking.

The infant did not respond to the guardians’ voices during that time.

The episode lasted approximately 5 min and the infant was sleeping soundly afterwards.

On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation.

The infant has no prior medical or surgical history.

Born full-term at 40 weeks to a birth mother who had regular prenatal visits.

Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Choice A rationale
Shingles, also known as herpes zoster, is a viral infection that causes a painful rash and is caused by the varicella-zoster virus, the same virus that causes chickenpox.
Choice B rationale
Tinea pedis is a foot infection due to a dermatophyte fungus. It is the most common dermatophyte infection and is particularly prevalent in hot, tropical, urban environments. Interdigital involvement is most commonly seen (this presentation is also known as athlete’s foot, although some people use the term for any kind of tinea pedis).
Choice C rationale
Fever blister, also known as cold sores, are caused by the herpes simplex virus. They are small, fluid-filled blisters that develop on the lips or around the mouth.
Choice D rationale
Pinworms are a type of parasite that lives in the lower intestine of humans. They are tiny, narrow worms. They are white and less than a half-inch long.

The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.

Rationale for each choice:

• Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
• Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
• Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
• Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.