Exhibits

A nurse is collecting data from an adolescent who has bacterial pneumonia. Which of the following findings is the priority for the nurse to 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.)

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.

Rationale for Correct Choices:

• Increased Intracranial Pressure: The infant's symptoms (irritability, vomiting, bulging anterior fontanel, and tense fontanel) suggest increased intracranial pressure, a potential complication of hydrocephalus and ventriculoperitoneal shunt malfunction.
• Measure head circumference: Measuring head circumference is essential in assessing for increased intracranial pressure, as it can help identify changes in the volume of the head due to fluid buildup.
• Insert nasogastric tube: Inserting a nasogastric tube is often necessary to manage vomiting and ensure adequate hydration and nutrition, especially when the infant is unable to feed properly due to increased intracranial pressure.
• Behavioural changes: Monitoring for changes in behaviour, such as lethargy or decreased responsiveness, is critical in assessing the progression of increased intracranial pressure.
• Pupillary response: Pupillary response is an important parameter to monitor because changes in the size, shape, and reactivity of the pupils can indicate increased intracranial pressure or brainstem involvement.

Rationale for Incorrect Choices:

• Paralytic ileus: While the infant is having stool issues, the primary symptoms of irritability, vomiting, and bulging fontanel are more indicative of increased intracranial pressure. Paralytic ileus is generally associated with absent bowel sounds and abdominal distension.
• Otitis media: Otitis media typically presents with fever, ear pain, and irritability, but the infant’s bulging fontanel, vomiting, and irritability are more suggestive of intracranial pressure. Otitis media does not cause neurological symptoms like a tense fontanel.
• Peritonitis: Peritonitis usually presents with abdominal distension, guarding, or signs of sepsis, which are not evident here. The infant’s symptoms point more towards neurological issues related to the ventriculoperitoneal shunt or increased intracranial pressure.
• Prepare the infant for myringotomy: Myringotomy is performed for severe ear infections with fluid accumulation behind the eardrum (otitis media), but the infant's presentation suggests a neurological issue, not an ear infection.
• Place the child in an infant seat: Placing the infant in an infant seat may provide temporary comfort but does not address the underlying neurological issue, and this action does not help manage the potential condition.
• Plan to assist with the administration of intravenous antibiotics: While infection (e.g., shunt infection leading to hydrocephalus) is a possibility, the immediate nursing actions focus on confirming and managing the elevated ICP.
• Bowel sounds: Monitoring bowel sounds is more relevant to gastrointestinal conditions, such as paralytic ileus or peritonitis, which are not the primary concern here.
• Tympanic perforation relates to an ear condition and is not a relevant parameter for monitoring increased intracranial pressure.
• Abdominal distension: Abdominal distension is usually associated with gastrointestinal problems like peritonitis or paralytic ileus. However, the infant’s clinical presentation (neurological symptoms) suggests increased intracranial pressure.