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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
When advising a new mother in caring for a child with croup, the symptom that should be a priority concern to the telephone triage nurse is B.
Explanation:
A. A fever of 101.0°F (38.3°C) is a common symptom in many childhood illnesses, including croup, but it is not the primary concern when difficulty swallowing secretions is present.
B Difficulty swallowing secretions.
Croup is characterized by a barking cough and may also be associated with stridor (noisy breathing), hoarseness, and difficulty swallowing secretions. While all the symptoms mentioned can be concerning, difficulty swallowing secretions is a priority concern because it can potentially lead to respiratory distress if not managed appropriately. Thick secretions can cause airway obstruction, and prompt assessment and intervention are needed to ensure the child's airway remains clear and that the child is able to breathe effectively.
C. A barking cough, worse at night, is a classic symptom of croup and should be addressed, but difficulty swallowing secretions can have a more direct impact on the child's airway.
D. Crying often when nursing may be related to the discomfort caused by croup, but it is not as immediately concerning as difficulty swallowing secretions.
While the barking cough, hoarseness, and other croup symptoms should also be addressed, the priority is ensuring that the child is able to manage secretions effectively without respiratory distress. The telephone triage nurse should provide guidance to the mother on how to help the child manage these secretions and when to seek medical attention if the situation worsens.
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