The nurse continues to care for the client.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis

Rationale:

A. Perform an ECG every 12 hr: Frequent ECGs are typically done during the acute phase to monitor for arrhythmias, but by day 3 post-MI, continuous or as-needed monitoring is more appropriate unless new symptoms occur.

B. Obtain a cardiac rehabilitation consultation: Early involvement of cardiac rehab supports gradual activity progression, lifestyle modification, and psychosocial support, improving long-term outcomes after MI.

C. Draw a troponin level every 4 hr: Troponin testing is most useful for diagnosing and trending damage during the first 24 hours; by day 3, levels have usually peaked and are declining.

D. Place the client in a supine position while resting: Supine positioning can increase cardiac workload; a semi-Fowler's position is preferred to reduce venous return and ease breathing.

Rationale for correct choices:

• Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
• Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
• Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
• Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
• Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

• Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
• Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.