The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?

Schedule a full neurological evaluation.

Recommend follow-up in 30 days after documenting the regression.

Question the parents about changes in the child's activity schedule.

Document the findings and schedule an 18-month well-visit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Scheduling a full neurological evaluation is the appropriate action in this scenario. The sudden regression in the child's ability to walk is a significant concern that requires immediate investigation to rule out any underlying neurological or medical conditions. A full neurological evaluation will help identify any issues such as developmental delays, neuromuscular disorders, or other conditions that may be affecting the child's motor skills. Prompt evaluation and diagnosis are crucial for early intervention and appropriate management.

Choice B reason: Recommending follow-up in 30 days after documenting the regression is not an ideal approach in this situation. Given the severity of the regression in the child's walking ability, waiting for 30 days without further investigation could delay critical diagnosis and treatment. Immediate assessment is necessary to address potential underlying issues and provide timely intervention.

Choice C reason: Questioning the parents about changes in the child's activity schedule is important but should not be the sole action taken. While gathering information about the child's activities and environment can provide valuable context, it does not replace the need for a thorough medical evaluation. The primary concern here is the sudden regression in motor skills, which warrants a full neurological assessment.

Choice D reason: Documenting the findings and scheduling an 18-month well-visit is also not sufficient. While it is essential to document the observed regression, delaying further action until the next routine check-up could result in missed opportunities for early diagnosis and intervention. The priority should be to conduct a neurological evaluation to understand the cause of the regression and take appropriate steps to address it.

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Correct Answer is ["64"]

Explanation

To calculate the maintenance IV fluid rate for a child, we typically use the Holliday-Segar formula:

For the first 10 kg of weight: 100 ml/kg/day
For the next 10 kg of weight: 50 ml/kg/day
For any additional weight: 20 ml/kg/day

The weight of the child is 48 pounds, which is approximately 21.8 kg (since 1 pound = 0.45 kg).

Using the formula:

First 10 kg: 100 ml/kg/day = 1000 ml/day
Next 10 kg: 50 ml/kg/day = 500 ml/day
Remaining 1.8 kg: 20 ml/kg/day = 36 ml/day

Total = 1000 ml + 500 ml + 36 ml = 1536 ml/day

To find the rate in ml/hr: 1536 ml/day ÷ 24 hours/day = 64 ml/hr

A. Prepare to hang hypotonic fluids. B. Administer oxygen via nasal cannula. C. Provide patient education on acute chest syndrome. D. Give a dose of morphine sulphate.

Correct Answer is B

Explanation

Choice A reason: Preparing to hang hypotonic fluids is not the immediate priority in this situation. While hydration is important for managing sickle cell anaemia, the infant's respiratory distress and low oxygen saturation levels indicate that addressing oxygenation should be the first step. Hypotonic fluids may be considered after stabilizing the patient's breathing and oxygen levels.

Choice B reason: Administering oxygen via nasal cannula is the priority intervention given the infant's symptoms. The infant has increased work of breathing, a fever, coarse crackles upon auscultation, and low oxygen saturation (89%). Providing supplemental oxygen is crucial to improve oxygenation and alleviate respiratory distress. Prompt intervention is necessary to prevent further complications and stabilize the patient's condition.

Choice C reason: Providing patient education on acute chest syndrome is important, but it is not the immediate priority in this emergency situation. Education can be given once the infant's acute symptoms are managed and stabilized. The focus should be on addressing the critical needs first, such as oxygenation and respiratory support.

Choice D reason: Giving a dose of morphine sulphate may help manage pain, but it is not the first priority in this scenario. The infant's respiratory status and oxygenation levels are more critical and require immediate attention. Pain management can be addressed after ensuring the infant's breathing and oxygen levels are stabilized.

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The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is calculating maintenance IV fluid requirements for a child who weighs 48 pounds. Using the continuous fluid maintenance formula, calculate the rate (ml/hr) the nurse will set the pump? Round to the nearest whole number. Enter the number only, no units.

Correct Answer is ["64"]

Explanation

The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?

Correct Answer is B

Explanation

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