A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full-thickness burn to 10% of his body. Which of the following findings should the nurse report to the provider?
Increased restlessness
Respiratory rate 25/min
Bowel sounds 20/min
Urinary output 35 mL/hr
The Correct Answer is A
A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased self-esteem is a positive aspect of development, but it may not be a consistent characteristic during early adolescence. Self-esteem can fluctuate based on various factors.
B. Mood swings are common during early adolescence due to hormonal changes and the emotional challenges that come with this stage of development. It's important for parents to be understanding and supportive during this time.
C. The growth rate during early adolescence may vary from person to person, but it generally accelerates rather than decelerates. This period is associated with rapid physical growth, known as the adolescent growth spurt.
D. Emotional separation from parents is a normal part of adolescent development, but it tends to become more prominent in later adolescence rather than early adolescence. During early adolescence, there may be a mix of seeking independence and still relying on parental support and guidance.
Correct Answer is A
Explanation
A. Hyperpyrexia, or extremely high fever, is a potential complication of acute
acetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.
B. Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.
C. Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.
D. Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.
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