A nurse is caring for an 8-year-old child on an inpatient pediatric unit.

Exhibits

Click to highlight the findings that indicate the client requires immediate follow-up. To deselect a finding, click on the finding again

 

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
Genitourinary	Output of 25 mL dark amber urine through catheter

Rationale for correct choices:

• Skin turgor: Poor skin turgor indicates dehydration, which can lead to electrolyte imbalances, hypotension, and renal complications. Immediate assessment and fluid management are necessary to prevent further physiological deterioration.
• Heart rate: A heart rate of 120/min is tachycardic. This can be caused by dehydration, stimulant effects of mania, or other underlying medical issues. It requires prompt monitoring and intervention to prevent cardiovascular compromise.
• Sleep pattern: The client has not slept for 2 days, which increases the risk for physical exhaustion, worsening psychiatric symptoms, and impaired judgment. Sleep deprivation in the context of mania requires immediate attention to stabilize the client.
• Hallucinations: The client reports listening to unseen others, indicating auditory hallucinations. This can pose a risk for self-harm or unsafe behaviors, and immediate psychiatric assessment and intervention are warranted.

Rationale for incorrect choice:

• Hygiene: While the client’s hair and clothing are unclean, indicating self-care deficits, this is not an immediate threat to physiological stability. It is important for overall care planning but does not require urgent intervention compared to dehydration, tachycardia, sleep deprivation, or hallucinations.

A. A client who is taking warfarin and has started to breastfeed: Warfarin passes into breast milk in very small amounts and is generally considered compatible with breastfeeding. However, the infant’s coagulation status should be monitored, and follow-up with the healthcare provider is appropriate to ensure safety.

B. A client who is taking bumetanide and reports an increase in urinary frequency: Increased urination is an expected pharmacologic effect of loop diuretics like bumetanide. This finding does not require follow-up unless accompanied by other concerning symptoms.

C. A client who received a Mantoux test 48 hr ago and has an induration: A positive Mantoux test requires interpretation by a healthcare provider, but the presence of induration alone is a normal finding that triggers standard follow-up for tuberculosis screening.

D. A client who is scheduled for a colonoscopy and is taking sodium phosphate: Sodium phosphate is commonly used as a bowel prep for colonoscopy. As long as the client follows the prescribed instructions and has no contraindications, this does not require additional follow-up.