A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take?

A. Maintain night splints to the affected joint: Night splints help maintain joint position and function during sleep, preventing contractures and deformities. This is a common intervention in managing juvenile rheumatoid arthritis to ensure proper joint alignment and minimize pain and stiffness.

B. Encourage the child to take daytime naps: Daytime naps can lead to prolonged periods of immobility, which may increase stiffness and pain in joints. Maintaining regular activity and exercise is usually recommended to preserve joint function.

C. Administer opioids on a schedule: Opioids are not typically first-line treatment for juvenile rheumatoid arthritis due to potential side effects and risk of dependence. Nonsteroidal anti-inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) are more commonly used.

D. Apply cool compresses for 20 min every hour: Cool compresses may provide temporary relief for acute joint pain but are not recommended on a regular schedule due to risk of skin damage and reduced joint flexibility. Heat application is more commonly used for chronic pain relief in arthritis.

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.