Which of the following findings should the nurse report to the health care provider immediately? (select all that apply)
Loss of appetite
Platelet count
Developmental regression
Absolute neutrophil count
Hemoglobin
Correct Answer : C,D
Choice A reason: Loss of appetite is not an urgent finding, as it may be caused by various factors, such as nausea, pain, or stress. The nurse should monitor the child's fluid and calorie intake and encourage oral hydration and nutrition. However, loss of appetite does not require immediate reporting to the health care provider.
Choice B reason: Platelet count is not an urgent finding, as it is not given in the text. The nurse should check the child's laboratory results and compare them with the normal ranges for preschoolers. A normal platelet count for children is 150,000 to 450,000 per microliter of blood¹. A low platelet count (thrombocytopenia) may indicate bleeding disorders, infections, or bone marrow problems. A high platelet count (thrombocytosis) may indicate inflammation, infection, or cancer. The nurse should report any abnormal platelet count to the health care provider, but it is not an immediate concern.
Choice C reason: Developmental regression is an urgent finding, as it may indicate a serious neurological problem, such as a brain tumor, infection, or injury. Developmental regression is the loss of previously acquired skills or milestones, such as language, motor, or social skills. The nurse should assess the child's developmental level and report any signs of regression to the health care provider as soon as possible.
Choice D reason: Absolute neutrophil count is an urgent finding, as it may indicate a severe infection or a compromised immune system. Neutrophils are a type of white blood cell that fight bacterial infections. The absolute neutrophil count is the number of neutrophils in a microliter of blood. A normal absolute neutrophil count for children is 1,500 to 8,000 per microliter of blood². A low absolute neutrophil count (neutropenia) may increase the risk of infection and sepsis. A high absolute neutrophil count (neutrophilia) may indicate an acute infection or inflammation. The nurse should report any abnormal absolute neutrophil count to the health care provider immediately.
Choice E reason: Hemoglobin is not an urgent finding, as it is not given in the text. The nurse should check the child's laboratory results and compare them with the normal ranges for preschoolers. Hemoglobin is a protein in red blood cells that carries oxygen. A normal hemoglobin level for children is 11.5 to 15.5 grams per deciliter of blood³. A low hemoglobin level (anemia) may indicate blood loss, iron deficiency, or bone marrow problems. A high hemoglobin level (polycythemia) may indicate dehydration, lung disease, or heart disease. The nurse should report any abnormal hemoglobin level to the health care provider, but it is not an immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not a statement that indicates a need for further teaching. The client is doing wheelchair exercises while watching TV, which is a good way to maintain physical activity and prevent muscle atrophy and contractures. The nurse should praise the client for this behavior and encourage them to continue.
Choice B reason: This is not a statement that indicates a need for further teaching. The client is carrying a water bottle with them and drinking a lot of water, which is a good way to prevent dehydration and urinary tract infections. The nurse should praise the client for this behavior and remind them to drink at least 2 liters of water per day.
Choice C reason: This is not a statement that indicates a need for further teaching. The client is using a suppository every night to have a bowel movement, which is a common method of managing bowel dysfunction in clients with spina bifida. The nurse should ask the client about their bowel routine and provide any additional education or support as needed.
Choice D reason: This is a statement that indicates a need for further teaching. The client is only catheterizing themselves twice every day, which is not enough to prevent urinary retention and infection. The nurse should explain to the client that they need to catheterize themselves at least every 4 to 6 hours, or as prescribed by the provider. The nurse should also demonstrate the proper technique and hygiene for catheterization and assess the client's ability to perform it.
Correct Answer is D
Explanation
Choice A reason: A low-sodium diet is not recommended for a child who has Addison's disease, as they need more sodium to maintain their blood pressure and fluid balance. A high-sodium diet may be advised instead. ¹
Choice B reason: Hyperglycemia, or high blood sugar, is not a common manifestation of Addison's disease, as the condition causes low levels of cortisol, which normally raises blood sugar. Hypoglycemia, or low blood sugar, is more likely to occur and should be monitored and treated. ²
Choice C reason: Fluid volume excess, or edema, is not a common complication of Addison's disease, as the condition causes low levels of aldosterone, which normally retains sodium and water in the body. Fluid volume deficit, or dehydration, is more likely to occur and should be prevented and corrected. ³
Choice D reason: Cortisol replacement therapy is the main treatment for Addison's disease, as it helps restore the normal function of the adrenal glands and prevent adrenal crisis. The parents should be taught about the dosage, timing, and side effects of the medication, as well as the signs and symptoms of underdose and overdose. They should also be instructed to increase the dose during times of stress, illness, or injury, and to carry an emergency injection kit. ⁴.
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