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 |
|
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. Administer fluid bolus immediately when the client arrives to the facility: Rapid fluid boluses are reserved for clients in hypovolemic shock. For burn resuscitation, fluids are calculated and administered according to formulas rather than as a one-time bolus.
B. Administer one-third of the total fluid volume for resuscitation within the first 12 hr: Burn fluid resuscitation formulas, such as the Parkland formula, typically require half of the total calculated fluids to be given within the first 8 hours post-burn, not 12 hours.
C. Calculate fluid volume for resuscitation beginning with client arrival time at the facility: Fluid calculation is based on the time of the burn occurrence, not the arrival time, to ensure accurate resuscitation over the initial 24 hours.
D. Use the total body surface area of the client's burns when calculating fluid volume for resuscitation: The extent of burns, expressed as a percentage of total body surface area (TBSA), is a key factor in calculating fluid needs. Accurate TBSA assessment ensures appropriate fluid resuscitation to maintain perfusion and prevent complications.
Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}
Explanation
- Lymphadenopathy: Generalized lymphadenopathy, or swelling of the lymph nodes, is a common symptom of measles and rubella, but not typically a defining feature of fifth disease.
- Koplik spots in the mouth: Pathognomonic for measles, appearing as tiny white lesions on the buccal mucosa before the rash. Their presence essentially confirms measles over other viral exanthems.
- Red rash on the face: Occurs in all three illnesses but with different patterns — measles starts at the hairline and spreads downward, rubella begins on the face and spreads quickly, and fifth disease presents with a “slapped cheek” appearance before spreading.
- Fever: Common to all three conditions but differs in severity — measles typically produces higher fevers, rubella causes mild fever, and fifth disease may have low-grade fever or none.
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