Exhibits
A nurse is collecting data from an adolescent who has a new diagnosis of infectious mononucleosis. Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Skin condition
Temperature
Pain level
Intake
The Correct Answer is C
A. Skin condition: The fine rash noted on the chest and abdomen is not itchy, which is a common finding in infectious mononucleosis. It is not a primary concern unless it worsens or develops other characteristics, but it is not the most urgent issue to report.
B. Temperature: The client's temperature of 38.2°C (100.8°F) is slightly elevated, which is typical in infectious mononucleosis. It is within the expected range for the condition, and the prescribed acetaminophen should help manage the fever.
C. Pain level: The client reports significant pain in the left upper quadrant (rated 8 on a scale of 0 to 10) that worsens with palpation. This could indicate splenic involvement, which is a serious complication of mononucleosis, as the spleen can become enlarged and rupture.
D. Intake: The client is drinking at least 8 cups of water per day and eating about 60% of meals, which is an adequate fluid intake for the current state. Although not perfect, the intake is not a primary concern at this time compared to the pain level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "You should position the car seat at a 30-degree angle." The correct angle for rear-facing car seats is 45 degrees. A 30-degree angle may cause the infant’s head to fall forward, increasing the risk of airway obstruction.
B. "You should place a folded blanket to pad the back of the infant's head." Extra padding behind or around the infant's head is not recommended as it may interfere with the seat’s effectiveness and safety in a crash.
C. "You should use a car seat with a four-point harness." The recommended harness system is a five-point harness, which provides more secure restraint at the shoulders, hips, and between the legs.
D. "You should place the retainer clip at the level of the infant's armpits." Correct placement of the retainer (chest) clip is at armpit level. This ensures that the harness straps stay positioned over the shoulders, reducing the risk of injury during a crash.
Correct Answer is C
Explanation
A. Reinforce with the guardians to avoid discussing death with the child's siblings: Avoiding the discussion of death with the child's siblings can create confusion and anxiety. It's important to foster open communication and allow siblings to process their emotions about the situation in an age-appropriate manner.
B. Guide discussions with the child about death: Discussions about death should be handled delicately, considering the child’s age and understanding; this should be done in partnership with the family and healthcare providers.
C. Use a calm tone of voice when speaking with the child: A calm, reassuring tone of voice is essential when interacting with a child in palliative care. This helps provide comfort, reduces anxiety, and establishes a sense of safety for the child during a difficult time.
D. Encourage the guardians to seek a second opinion about their child's diagnosis:
Seeking a second opinion may be an option in some situations, but in the context of palliative care, the focus is typically on comfort and quality of life rather than pursuing further curative treatments.
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