Patient Data

Exhibits

Chart is reviewed.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale for Correct Choices:

• Sickle cell crisis: The infant’s pallor, edema in hands and feet, irritability, poor feeding, decreased urine output, and recent infection align with a vaso-occlusive episode typical in sickle cell disease.

•IV and oral fluids decrease blood viscosity and improve circulation, which is essential to prevent worsening of vaso-occlusion and associated pain.

• As able, elevate extremities: Elevating affected extremities promotes venous return, reduces swelling, and alleviates discomfort during the crisis.

• Intake and output: Monitoring fluid balance is critical to detect dehydration or renal compromise, which are risks in sickle cell crises due to reduced perfusion and poor intake.

• White blood cell count: WBC monitoring helps detect infection, which can trigger or worsen a sickle cell crisis, and assesses the body’s inflammatory response during the acute event.

Rationale for Incorrect Choices:

• Leukemia: While leukemia can present with pallor and fatigue, the acute swelling of hands and feet, irritability, and trigger by recent infection are more characteristic of sickle cell crisis rather than leukemia.

• Pneumonia: Adventitious lung sounds are noted, but the primary presenting signs (pallor, extremity edema, decreased urine output, pain) are more consistent with sickle cell crisis; pneumonia alone would not explain extremity edema.

• Potential Condition: Stroke: Stroke in infants may cause focal neurological deficits or asymmetric movement, but this infant shows generalized extremity involvement without focal weakness, making stroke less likely.

• Initiate sliding scale insulin: There is no evidence of hyperglycemia requiring insulin; blood glucose monitoring is not indicated for the acute presentation.

• Cool the environment: Cooling can worsen vasoconstriction and precipitate a sickle cell crisis; it is contraindicated in vaso-occlusive episodes.

• Begin bilirubin light therapy: The infant does not present with jaundice or hyperbilirubinemia; phototherapy is not indicated.

• Blood glucose: There is no indication of hypoglycemia or hyperglycemia contributing to this presentation, so monitoring glucose is not priority.

• Clotting times: There is no evidence of coagulopathy or bleeding disorder in this scenario; monitoring clotting times is unnecessary.

• Bilirubin: The infant has no jaundice or lab evidence of hyperbilirubinemia, making bilirubin monitoring nonessential.

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Correct Answer is C

Explanation

A. Monitor for desquamation and normal flora overgrowth: While monitoring skin integrity is important, this does not directly prevent the primary complication of scabies, which is secondary bacterial infection from scratching.

B. Wash skin between application of topical antiparasitic doses: Washing between doses can remove the medication prematurely, reducing its effectiveness. The lotion should remain on for the prescribed time before being washed off.

C. Keep the child's nails short and encourage use of hand mittens: Trimming nails and using mittens reduce scratching and skin breakdown, which lowers the risk of bacterial superinfection, the main complication of scabies in children.

D. Shave the body hair before applying the scabicide lotion: Shaving is not recommended, as scabicide is effective when applied to the skin surface. Shaving may cause irritation and increase discomfort without improving treatment outcomes.

A. Complete blood count. B. Skin biopsy. C. Allergy test. D. Electromyography.

Correct Answer is A

Explanation

A. Complete blood count: Zidovudine can cause bone marrow suppression, leading to thrombocytopenia. Pinpoint red spots, or petechiae, are a sign of low platelet count. A CBC is the most relevant test to evaluate for cytopenias and should be reported promptly to the provider.

B. Skin biopsy: A biopsy would help diagnose dermatologic conditions such as rashes, lesions, or malignancies, but petechiae are usually vascular in nature and related to platelet abnormalities.

C. Allergy test: Allergy testing evaluates hypersensitivity to specific allergens but is not relevant here. Petechiae are not typical of allergic reactions; instead, they reflect impaired clotting or low platelets.

D. Electromyography: EMG measures electrical activity in muscles to assess for neuromuscular disorders. It has no connection to the client’s presentation of petechiae and is unrelated to zidovudine’s known adverse effects.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a child who is suffering from persistent itching due to scabies. Which measure should the nurse implement to minimize this child's risk for complications?

Correct Answer is C

Explanation

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

Correct Answer is A

Explanation

A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

A client's respiratory assessment reveals crackles, decreased tactile fremitus, and a dull sound in left lower chest during percussion. Which condition should the nurse document in the electronic medical record?

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

A client admitted with a diagnosis of appendicitis calls the nurse and states, "Do you think I'll still need surgery? My pain suddenly stopped, and I feel much more comfortable now when I bend my knees." Which action should the nurse take?

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.