A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?

A client who has a burn injury to an estimated 5% of his leg and is crying

A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation

A who is a client 1 day postoperative and has a temperature of 37.5° C (99.5° F)

A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing

Answer and Explanation

The Correct Answer is D

D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.

The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.

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Correct Answer is D

Explanation

D. "My child will take the enzymes to help digest the fat in foods."
Cystic fibrosis (CF) affects the exocrine glands, leading to thick and sticky mucus production, which can block the pancreatic ducts. As a result, children with CF have difficulty digesting fats and absorbing fat-soluble vitamins. Pancreatic enzyme replacement therapy (PERT) is prescribed to help improve fat digestion and nutrient absorption. These enzymes are taken with meals and snacks to aid in the breakdown of fats.
The other options are incorrect:
A. "My child will take the enzymes following meals." - This is the correct timing for taking pancreatic enzymes. The enzymes should be taken with meals and snacks, not following meals.
B. "My child will take the enzymes to improve her metabolism." - The purpose of taking pancreatic enzymes is not related to improving metabolism but to assist in fat digestion and nutrient absorption.
C. "My child will take the enzymes 2 hours before meals." - Taking pancreatic enzymes 2 hours before meals is not the recommended timing. They should be taken with meals and snacks to aid in fat digestion while eating.

A. "We will restrict the amount of salt in our child's food." B. I will limit my child's fluid intake." C. "I will prepare low-fat meals with limited protein for my child." D. "We will give our child pancreatic enzymes with snacks and meals."

Correct Answer is D

Explanation

Cystic fibrosis (CF) is a genetic disorder that affects the production and function of certain glands, particularly those that produce mucus and sweat. One of the key aspects of CF management is addressing the pancreatic insufficiency that occurs in many individuals with CF. Due to the impairment of the pancreas, children with CF may have difficulty digesting food properly, especially fats. This can lead to malabsorption of nutrients, poor weight gain, and other nutritional deficiencies.

Pancreatic enzyme replacement therapy is a crucial part of CF management. Pancreatic enzymes are prescribed to help the child digest and absorb essential nutrients, especially fats. The enzymes are typically given with each meal and snack to aid in the breakdown and absorption of nutrients.

The other options are not correct:

A. "We will restrict the amount of salt in our child's food."

Sodium restriction is generally not a focus in CF management unless there are specific indications for it. CF patients may have increased salt losses in sweat, but dietary sodium restriction is not a primary aspect of their care.

B. "I will limit my child's fluid intake."

Fluid intake is important for children with CF to maintain hydration and prevent dehydration. There is no specific need to limit fluid intake unless there are individualized medical reasons for doing so.

C. "I will prepare low-fat meals with limited protein for my child."

Children with CF often require a high-calorie, high-protein diet to maintain adequate nutrition and growth. Restricting fat and protein intake is not typically recommended, as these nutrients are essential for a child's development and well-being. Instead, pancreatic enzymes are used to aid in the digestion and absorption of fats and other nutrients.

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A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?

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Naxlex Comprehensive Predictor Exams

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