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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Report the assessment to the healthcare provider.

The changing color of the inguinal hernia to dark purple is concerning and may indicate a possible strangulated hernia, which is a surgical emergency. Additionally, the absence of a bowel movement for 24 hours raises concerns about possible bowel obstruction or compromise. The FLACC score of 8 on the initial assessment suggests that the infant is experiencing significant discomfort or pain.

Therefore, the priority is to report the assessment findings to the healthcare provider to ensure timely evaluation and intervention. The healthcare provider needs to assess the hernia, determine if it is strangulated, and decide on the appropriate course of action, which may include surgery. It is essential to act promptly in this situation to prevent potential complications.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

D. Preparing to initiate venous access for an intravenous (IV) infusion is a consideration but should follow the assessment and reporting of the potential surgical emergency. Intravenous access may be needed as part of the overall management, but the priority is to ensure the infant receives appropriate surgical evaluation and intervention.

A. Report the assessment to the healthcare provider.

B. Determining when oral fluids were last taken is relevant but should not take precedence over the potential surgical emergency of a strangulated hernia.

C. Attempting to reduce the hernia manually is not advisable in this situation, as it may worsen the condition if the hernia is strangulated.

A. Encourage the parents rest when possible. B. Apply lotion to hands and feet. C. Make a list of foods that the child likes. D. Place the child in a quiet environment.

Correct Answer is D

Explanation

A. Encourage the parents to rest when possible.While ensuring that parents get rest is important for overall family well-being, this intervention does not directly address the child's immediate symptoms.

B. Apply lotion to hands and feet.Applying lotion can help soothe the discomfort associated with skin peeling. However, this intervention is more supportive and addresses a later concern. It does not directly alleviate the child's irritability or refusal to eat.

C. Make a list of foods that the child likes.This intervention focuses on improving the child's nutritional intake by offering familiar foods. However, if the child is irritable and overstimulated, their refusal to eat may be due to discomfort or distress. Addressing the irritability first may improve their willingness to eat.

D. Place the child in a quiet environment.Children with Kawasaki disease often experience irritability due to discomfort, fever, and the overall systemic effects of the illness. Creating a quiet environment helps reduce sensory stimulation, which can soothe the child and decrease irritability.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is imitable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

Correct Answer is D

Explanation

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