Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Neurological assessment

Basic metabolic panel

Blood pressure/heart rate

Abdominal assessment

Complete blood count

Pain assessment

Answer and Explanation

Correct Answer : A,B,C,E,F

A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.

B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.

C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.

D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.

E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.

F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.

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Correct Answer is ["A","C","E"]

Explanation

A. Most children with febrile seizures do not require seizure medicine is correct. Febrile seizures are typically self-limiting and do not require daily anticonvulsant therapy. Most children outgrow them.
B. My child's 4-year-old sibling is also at high risk for febrile seizures is incorrect. Febrile seizures most commonly occur in children between 6 months and 5 years old, so the 4-year-old sibling is not necessarily at high risk.
C. I will give my child acetaminophen when she has a fever to prevent her temperature from rising rapidly is correct. While acetaminophen may help lower fever, it should be used cautiously and only to prevent fever from becoming very high quickly.
D. My child will now take anticonvulsants every day to prevent seizures is incorrect. Anticonvulsants are generally not needed for febrile seizures unless there is a specific medical indication, such as recurrent seizures not related to fever.
E. My child could have another febrile seizure is correct. Children who have had a febrile seizure are at an increased risk of experiencing another one, especially if they continue to have fevers.

A. Respiratory rate B. Blood pressure C. Body weight D. Skin integrity

Correct Answer is C

Explanation

A. Respiratory rate can be influenced by many factors, including fever or anxiety, and is not the most reliable indicator of fluid loss.

B. Blood pressure may change with severe dehydration, but it can be a late sign, and other factors (like shock) can also affect blood pressure, so it's not the most reliable early indicator.

C. Body weight is the most reliable and sensitive indicator of fluid loss, as even small changes in weight reflect changes in hydration status. Monitoring weight helps assess fluid loss accurately.

D. Skin integrity can be affected by dehydration, but it's not the most reliable indicator of fluid loss. It may take longer to show visible signs such as dry skin or poor turgor.

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Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching to the parents of a toddler who experienced a febrile seizure. The nurse knows that the parents understand the teaching when the parents make which statement(s)? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is C

Explanation

A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

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