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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Nausea and vomiting: Gastrointestinal symptoms such as nausea, vomiting, and anorexia are common early signs of digoxin toxicity and should be closely monitored.

B. Fatigue and weakness: Generalized fatigue and muscle weakness can result from digoxin toxicity due to its effects on cardiac output and electrolyte imbalances, indicating early toxicity.

C. Bradycardia: Digoxin increases vagal tone, which can lead to bradycardia. A heart rate below 60 bpm is a key warning sign of digoxin toxicity.

D. Visual disturbances (e.g., yellow-green halos): Visual changes, including blurred vision, yellow-green halos, or altered color perception, are classic manifestations of digoxin toxicity and require prompt recognition.

E. Hypertension: Hypertension is not typically associated with digoxin toxicity; digoxin more commonly causes bradyarrhythmias and hypotension rather than elevated blood pressure.

A. Thirst. B. Increased appetite. C. Heat intolerance. D. Tachycardia. E. Urinary frequency.

Correct Answer is ["A","D","E"]

Explanation

A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.

B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.

C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.

D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.

E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

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