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 D
Explanation
A. Provide the client with periods of alone time for reflection on their behavior: While reflection can be helpful, unsupervised alone time may increase the risk of relapse in clients with alcohol use disorder and does not actively promote self-control.
B. Discuss strategies with the client to reduce alcohol consumption gradually: Gradual reduction is not always safe due to the risk of withdrawal complications. Abstinence under supervision is the recommended approach for alcohol use disorder.
C. Have the client's partner assume responsibility for monitoring the client's alcohol intake: Delegating responsibility to a family member undermines the client’s autonomy and does not foster personal self-control or coping skills.
D. Give positive feedback to the client for using adaptive coping strategies: Reinforcing the use of healthy coping mechanisms encourages self-control, builds confidence, and promotes continued use of adaptive strategies to manage stress without relying on alcohol.
Correct Answer is A
Explanation
Rationale:
A. Weight loss: Furosemide is a loop diuretic that promotes excretion of excess fluid through urine. A reduction in body weight reflects fluid loss and indicates that the medication is effectively managing fluid volume excess.
B. Decreased inflammation: Furosemide does not have anti-inflammatory properties. While it may reduce edema associated with fluid overload, it does not directly affect inflammatory processes in tissues.
C. Decreased pain: Pain reduction is not a direct effect of furosemide. Any perceived relief might occur secondarily if edema-related pressure is relieved, but it is not a primary measure of medication effectiveness.
D. Increased blood pressure: Furosemide typically lowers blood pressure by reducing intravascular volume. An increase in blood pressure would suggest that fluid overload is not being adequately managed or that another condition is influencing blood pressure.
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