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A nurse is caring for a toddler admitted to the hospital.

Exhibits

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

A.

Capillary refill 4 seconds

B.

Hyperactive bowel sounds

C.

Diaper area reddened with erythema noted

D.

Extremities cool

E.

Reports no tears

F.

Lethargic

G.

Respiratory rate 26/min

H.

Heart rate 112/min

Answer and Explanation

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.


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Related Questions

Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings

Sprain

Fracture

Dislocation

Ecchymosis

✅

✅

✅

Pain level

✅

✅

✅

Edema

✅

✅

✅

Sensation

✅

✅

Rationale:

Ecchymosis (bruising):

Sprain: Common due to soft tissue damage.

Fracture: Frequently present due to bone and soft tissue injury.

Dislocation: Bruising often accompanies joint dislocation.

Pain level:

Sprain: Moderate pain, often exacerbated by movement.

Fracture: Pain is typically sharp and worsens with movement or weight-bearing.

Dislocation: Severe pain due to misalignment of the joint.

Edema:

Sprain: Common due to inflammation from ligament injury.

Fracture: Swelling is typical around the fracture site.

Dislocation: Edema occurs due to joint misalignment and tissue trauma.

Sensation (tingling):

Sprain: Nerve compression or irritation may cause tingling.

Fracture: Tingling can result from nerve involvement or swelling near the fracture site.

Dislocation: Tingling is less common unless nerve damage occurs, which is more serious and often leads to numbness or motor impairment.

Correct Answer is D

Explanation

A. Diabetes insipidus does not cause hypoglycemia, so this is not relevant.

B. Capillary refill time is unrelated to diabetes insipidus management.

C. A heart rate of 140/min is tachycardic and may indicate dehydration or other complications, not medication effectiveness.

D. Desmopressin reduces excessive urine output, and a cessation of nocturnal enuresis (bedwetting) indicates improved fluid balance and medication effectiveness.

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