A nurse is caring for a toddler admitted to the hospital.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
|
Body Systems |
Findings |
|
Respiratory |
Respiratory rate 26/min |
|
Cardiovascular |
Heart rate 112/min Capillary refill 4 seconds |
|
Gastrointestinal |
Hyperactive bowel sounds |
|
Integumentary |
Diaper area reddened with erythema noted Extremities cool Reports no tears |
|
Neurologic |
Lethargic |
Capillary refill 4 seconds
Hyperactive bowel sounds
Diaper area reddened with erythema noted
Extremities cool
Reports no tears
Lethargic
Respiratory rate 26/min
Heart rate 112/min
The Correct Answer is ["A","B","C","D","E","F"]
Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.
Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.
Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.
Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.
Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","G"]
Explanation
|
System |
Findings |
|
General |
Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me." |
|
Physical |
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min |
|
Affect |
Client says, "Why don't you just leave me? I am of no use." |
Rationale
These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.
Correct Answer is C
Explanation
A. Exclude nutritional supplements from the list of medications the client reports: Incorrect. Nutritional supplements are medications and should be included in the medication reconciliation process.
B. Encourage the client to make his own list after he returns to his home: Incorrect. The nurse should be responsible for gathering the complete medication history upon admission, not relying on the client’s list from home.
C. Compare new prescriptions with the list of medications the client reports: This is the correct step in medication reconciliation. The nurse needs to ensure that new medications are compatible with the client's current medications and review any changes.
D. Include any adverse effects of the medications the client might develop: Incorrect. Adverse effects are not part of the medication reconciliation process; the focus is on identifying all current medications, including prescriptions, over-the-counter drugs, and supplements.
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