A nurse is caring for an adolescent who was brought to the emergency department (ED) with a fever, headache, and neck stiffness. The nurse should determine the assessment findings are consistent with which of the following disease processes?

Choice A reason: Tremors are not a likely finding in a child with hyperglycemia, or high blood glucose. Tremors are more commonly associated with hypoglycemia, or low blood glucose, as the body releases adrenaline to stimulate the release of glucose from the liver. Tremors may also be caused by anxiety, caffeine, or certain medications.

Choice B reason: Shallow respirations are not a likely finding in a child with hyperglycemia, unless the child has developed diabetic ketoacidosis (DKA), a serious complication of diabetes that occurs when the body breaks down fat for energy and produces ketones, which are acidic substances that can cause metabolic acidosis. In DKA, the child may have rapid and deep breathing, also known as Kussmaul respirations, as the body tries to eliminate excess carbon dioxide and acid. However, DKA usually occurs when the blood glucose level is above 300 mg/dL, and the child may also have other signs and symptoms, such as nausea, vomiting, abdominal pain, fruity breath, and confusion.

Choice C reason: Pallor is not a likely finding in a child with hyperglycemia, as the blood flow to the skin is not affected by high blood glucose. Pallor is more commonly associated with anemia, shock, or hypoxia, which are conditions that reduce the oxygen-carrying capacity of the blood or the blood flow to the tissues.

Choice D reason: Lethargy is a likely finding in a child with hyperglycemia, as high blood glucose can cause dehydration, electrolyte imbalance, and impaired brain function. The child may feel tired, weak, and drowsy, and have difficulty concentrating or staying awake. Lethargy may also indicate that the child is at risk of developing DKA, which can lead to coma and death if not treated promptly.

Choice A reason: A 2-year-old toddler is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 2-year-old toddler may receive the meningococcal polysaccharide (MPSV4) vaccine instead, if indicated.

Choice B reason: A 4-month-old infant is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 4-month-old infant may receive the meningococcal serogroup B (MenB) vaccine instead, if indicated.

Choice C reason: An 11-year-old school-age child is a recommended recipient of the MCV4 vaccine, as it is routinely given to children aged 11 to 12 years old, with a booster dose at age 16. The MCV4 vaccine protects against four types of meningococcal bacteria (A, C, W, and Y) that can cause serious infections of the lining of the brain and spinal cord (meningitis) or the bloodstream (septicemia).

Choice D reason: A 4-year-old child is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 4-year-old child may receive the meningococcal polysaccharide (MPSV4) vaccine instead, if indicated.