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. "You should be prepared to answer your child's questions about dying." is appropriate because children at this age may have questions about death and dying. It is important for the guardian to be honest and provide age-appropriate answers to help the child understand and cope with their situation.
B. While younger children often view death as temporary, a 10-year-old child typically has a more developed understanding of the finality of death. This statement might not be accurate for this age group.
C. Hiding grief is not recommended as it can create an atmosphere of secrecy and fear. It is better to model healthy expressions of emotions and provide support for the child's feelings.
D. Limiting visits between siblings may not be necessary and can be detrimental. Sibling support can be very important for both the ill child and the sibling, providing comfort and a sense of normalcy.
Correct Answer is C
Explanation
A. Nasal discharge negative for glucose indicates that there is no cerebrospinal fluid (CSF) leakage, which is a positive sign. While it is important to note, it is not the priority in this situation.
B. A negative Babinski reflex is a normal finding in children older than 2 years. It does not indicate an acute issue and is not the priority.
C. Asymmetric pupils can be a sign of increased intracranial pressure or a serious brain injury, making this the priority finding. It requires immediate attention to prevent further complications.
D. A 2 cm scalp laceration, while needing medical attention, is not life-threatening and is not the highest priority compared to potential brain injury indicated by asymmetric pupils.
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