A nurse is assisting with the care of a 15-year-old adolescent who has Streptococcus pneumonia.
The nurse is collecting data on the adolescent 24 hr later. How should the nurse interpret the findings?
For each finding, click to specify whether the finding is unrelated to the admitting diagnosis, an indication of potential improvement, or an indication of potential worsening condition.
WBC count 17,000/mm3
Steatorrhea
Oxygen saturation 95% on 1 L oxygen via nasal cannula
Barrel chest
Hemoptysis 300 ML
Respiratory rate 32/min
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"B"}}
WBC count 17,000/mm3: Indication of Potential Improvement. The initial WBC count was 22,000/mm3, and 24 hours later, it has decreased to 17,000/mm3, indicating improvement.
Steatorrhea: Unrelated to Diagnosis. This symptom is typically associated with cystic fibrosis rather than pneumonia.
Oxygen saturation 95% on 1 L oxygen via nasal cannula: Indication of Potential Improvement. The decrease in oxygen requirement from 2 L to 1 L suggests the adolescent's respiratory status may be improving.
Barrel chest: Unrelated to Diagnosis. This physical finding is more indicative of chronic conditions such as cystic fibrosis rather than an acute pneumonia presentation.
Hemoptysis 300 mL: Indication of Potential Worsening Condition. The presence of significant hemoptysis indicates a worsening condition, possibly due to progression or complications of pneumonia.
Respiratory rate 32/min: Indication of Potential Improvement. The decrease in respiratory rate from 36/min to 32/min suggests a possible improvement in respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Placing a folded blanket or any soft object under the child's head helps to protect the head from injury during the seizure. Ensuring safety is a priority during a seizure.
B. Putting a tongue blade or any object between the child's teeth can cause injury to the child. It is no longer recommended to place anything in the mouth during a seizure.
C. Magnesium sulfate is not indicated for treating tonic-clonic seizures. The focus should be on maintaining safety and monitoring the seizure.
D. Preventing movement of the child's extremities can cause injury. Instead, the nurse should protect the child from harm and ensure the environment is safe.
Correct Answer is D
Explanation
A. While loss of family income can contribute to stress and depression, it is not the highest risk factor for suicide.
B. Parental substance use disorder can increase the risk of suicidal behaviors in adolescents, but not as significantly as mental health disorders.
C. Parental divorce can be a stressor, but it is not the highest risk factor for suicide completion.
D. Bipolar disorder significantly increases the risk of suicide in adolescents due to the severe mood swings and potential for depressive episodes.
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