A nurse is caring for an 8-year-old child on an inpatient pediatric unit.
|
Body System |
Findings |
|
Integumentary |
Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze. |
|
Vital Signs |
Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min |
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Genitourinary |
Output of 25 mL dark amber urine through catheter |
Skin feels cool to the touch.
Capillary refill 3 seconds in left foot
Dressing on left hand shows small amount of moisture through gauze.
Blood pressure 102/50 mm Hg
Temperature 35.8° C (96.4° F)
Respiratory rate 20/min
Output of 25 mL dark amber urine through catheter
The Correct Answer is ["A","B","D","E","G"]
Rationale for correct choices:
- Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
- Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
- Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
- Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
- Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.
Rationale for incorrect choices:
- Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
- Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E,A,C,B,D
Explanation
Rationale:
A. Verbally remind the staff member of the expected behaviour changes: After the initial meeting, a verbal reminder reinforces expectations and gives the staff member an opportunity to improve without formal penalties.
B. Suspend the staff member from work for several days: Suspension is used when prior interventions have not resulted in improvement. It serves as a serious consequence, giving time for reflection before returning to work.
C. Give the staff member a written warning about the behavior: A written warning follows a verbal reminder if the unprofessional behavior continues. It creates a formal record and communicates the seriousness of the issue.
D. Dismiss the staff member from employment at the facility: Termination is the final step when all other corrective measures have failed and the behavior persists, ensuring workplace standards and safety are maintained.
E. Set up a meeting to speak with the staff member about the behavior: The first action is to meet privately to discuss the observed behavior, clarify expectations, and begin the progressive discipline process in a constructive manner.
Correct Answer is D
Explanation
Rationale:
A. Case manager: A case manager coordinates overall care and resources for clients but does not provide direct interventions to improve fine motor skills affected by neuropathy.
B. Physical therapist: Physical therapy focuses on improving gross motor function, strength, balance, and mobility, rather than fine motor activities like buttoning clothes.
C. Social worker: Social workers assist with psychosocial support, community resources, and counseling, but they do not address functional limitations caused by neuropathy.
D. Occupational therapist: Occupational therapy specializes in helping clients perform activities of daily living (ADLs) and can provide adaptive techniques or devices to improve fine motor function, such as buttoning clothes, which is appropriate for this client’s needs.
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