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
Explanation
A. Socialization can promote trust and reduce isolation, so limiting socialization is not beneficial.
B. Speaking in a neutral tone helps build trust and reduces perceived threats in clients with paranoid personality disorder, who may be suspicious of others' intentions.
C. Consistency in caregivers fosters trust, so rotating staff frequently may exacerbate the client's paranoia.
D. Mixing medication with food without the client's knowledge breaches trust and ethical guidelines.
Correct Answer is C
Explanation
A. Assessing IV patency is important but comes after confirming the client is not allergic.
B. Checking compatibility ensures safe administration but is not the first priority.
C. Reviewing the client's allergy history is the priority to prevent a potentially life-threatening allergic reaction.
D. Obtaining the medication is necessary but only after confirming it is safe for the client.
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