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The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.

Review H and P, laboratory results, flow sheet, and orders.

The nurse receives the report from the lab and documents the intake and output for 1600.

Based on the client's information at 1600, what symptoms should the nurse look for? Select all that apply.

Edema

Irritability

Fatigue

Dry skin

Intense thirst

Muscle weakness

Hypertension

Answer and Explanation

Correct Answer : A,D,E,F

A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.

D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.

E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.

F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.

B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.

The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Normal gait can be expected with appropriate management and treatment for clubfoot. With early and effective intervention, many children with clubfoot can achieve a normal gait.

B. Growth and development are not typically delayed as a long-term outcome of clubfoot when it is appropriately managed. The goal of treatment is to achieve normal foot development and function.

C. While heredity can play a role in clubfoot, it is not typically a sole determinant of the outcome. The success of treatment primarily depends on the timeliness and effectiveness of the interventions.

D Correction will require serial casting.

Unilateral clubfoot is a congenital deformity of the foot that can often be effectively managed with non-surgical interventions. Serial casting is a common and successful approach used to gradually correct the deformity. Parents should be informed that serial casting is likely to be a part of the treatment plan for their child's clubfoot.

Therefore, it is essential to educate parents that correction of unilateral clubfoot will likely require serial casting and that with appropriate treatment, the child can achieve a normal gait and experience normal growth and development.

A. Administer pain medication based on the FACES pain scale. B. Include the prone position in the every 2 hour turning schedule, C. Careful bathing and handling that avoids abdominal manipulation. D. Give antiemetic medications to prevent nausea and vomiting.

Correct Answer is C

Explanation

A. Administering pain medication based on the FACES pain scale is not the most relevant intervention in the preoperative period for a Wilms' tumor. Pain management may be addressed postoperatively, as needed.

B. Including the prone position in the every 2-hour turning schedule may not be the most appropriate intervention, as it may not be suitable for an infant with a Wilms' tumor, considering the location and potential size of the tumor.

C. Careful bathing and handling that avoids abdominal manipulation.

Wilms' tumor, also known as nephroblastoma, is a pediatric kidney cancer. Prior to surgery, it's crucial to handle the infant with care and avoid any abdominal manipulation to prevent any further complications or disruption to the tumor. This involves gentle handling and avoiding activities that may put pressure on the tumor or cause discomfort to the infant.

D. Giving antiemetic medications to prevent nausea and vomiting is a potential intervention, but it may be more relevant in the postoperative period, and its necessity would depend on the infant's individual condition and the surgical plan.

The priority during the preoperative period for an infant with a Wilms' tumor is to handle the infant carefully and avoid any actions that could exacerbate the condition or cause discomfort. The specific surgical plan and other preoperative preparations would be determined by the healthcare provider.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant with unilateral clubfoot. Which information should the nurse include in parent education about long-term outcomes?

Correct Answer is D

Explanation

An infant who has a Wilms' tumor is admitted for surgery. Which intervention should the nurse implement during the preoperative period?

Correct Answer is C

Explanation

The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother?

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?

The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?