A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?

Increased seizure activity

• Finding: Phenytoin level

The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.

Pneumonia

• Finding: Cough

A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.

Liver failure

• Finding: Skin rash

Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.

Steven-Johnson syndrome

• Finding: Liver enzymes

Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.

Pneumothorax

• Finding: Lung sounds

A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.

A. "I will notify the doctor if his temperature is not controlled with acetaminophen." Notifying the doctor if the temperature is not controlled with acetaminophen is appropriate, as persistent fever might indicate a more severe infection or other complications.

B. "I will continue to check his blood sugar two times every day." Checking blood sugar only twice a day is insufficient during illness, especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection, and more frequent monitoring (at least 4 times a day or as recommended) is necessary.

C. "I will report changes in breathing or signs of confusion." Reporting changes in breathing or signs of confusion is essential, as these can be signs of worsening infection, respiratory distress, or diabetic ketoacidosis, which requires immediate medical attention.

D. "I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes." Encouraging fluid intake is important to prevent dehydration and help manage blood glucose levels during illness. Ensuring adequate hydration with water or sugar-free fluids is appropriate.