A nurse is caring for a 10-year-old male child.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
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Body system |
Findings |
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Neurological
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Generalized muscle weakness noted in bilateral lower extremities. Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10. Patellar deep tendon reflexes 1+ bilaterally. Child is awake and alert, responds appropriately to questions. |
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Gastrointestinal |
Abdomen slightly firm, bowel sounds hypoactive. Reports last bowel movement was 3 days ago. |
Generalized muscle weakness noted in bilateral lower extremities
Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10
Abdomen slightly firm, bowel sounds hypoactive
Reports last bowel movement was 3 days ago
Child is awake and alert, responds appropriately to questions
The Correct Answer is ["A","B","C","D"]
Findings that require immediate follow-up:
- Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
- Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
- Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.
Findings that do not require immediate follow-up:
- Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
- Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["12.5"]
Explanation
Dose required per day = 50mg/kg/day × 40 kg = 2000 mg/day
Dose per administration = 2000mg4 doses= 500 mg/dose
Volume to administer:
200mg5ml=40mg/ml
500mg40mg/ml=12.5ml/dose
Correct answer =12.5mL/dose
Correct Answer is []
Explanation
Condition Most Likely Experiencing: Bronchiolitis
The infant's symptoms—fever, cough, nasal congestion, wheezing, nasal flaring, intercostal retractions, and difficulty feeding—are characteristic of bronchiolitis, commonly caused by RSV in infants.
Actions to Take:
- Administer Oxygen via nasal cannula: The infant's low oxygen saturation (88% on room air) and respiratory distress (nasal flaring, retractions) indicate the need for supplemental oxygen to ensure adequate oxygenation and reduce respiratory distress.
- Suction nares with a bulb aspirator: Suctioning the infant’s nasal passages helps clear mucus and improve breathing. Infants with RSV often have significant nasal congestion that can impair feeding and breathing, so clearing the airways is crucial for respiratory management.
Parameters to Monitor:
- Oxygen saturation via continuous pulse oximetry: Monitoring oxygen saturation provides critical information on the infant’s respiratory status and helps assess the effectiveness of oxygen therapy.
- Respiratory effort and breath sounds: The infant is showing signs of increased respiratory effort (e.g., nasal flaring, intercostal retractions) and abnormal breath sounds (e.g., wheezes). Monitoring these parameters helps assess the severity of respiratory distress and guides further interventions.
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