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

Answer and Explanation

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.

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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.

A. intravenous immunoglobulin. B. oral acyclovir. C. intramuscular penicillin. D. topical hydrocortisone.

Correct Answer is A

Explanation

Choice A reason: Intravenous immunoglobulin is a likely prescription, as it is used to treat Kawasaki disease, which is a rare but serious condition that causes inflammation of the blood vessels in children. The toddler has many signs and symptoms of Kawasaki disease, such as high fever, irritability, red eyes, dry lips, strawberry tongue, swollen hands and feet, rash, and enlarged lymph node. Intravenous immunoglobulin can reduce the risk of complications, such as coronary artery aneurysms, which can be life-threatening.

Choice B reason: Oral acyclovir is not a probable prescription, as it is used to treat viral infections, such as herpes simplex or varicella zoster, which are not the main problems of the toddler. The toddler has no evidence of a viral infection, such as blisters, vesicles, or crusts.

Choice C reason: Intramuscular penicillin is not a likely prescription, as it is used to treat bacterial infections, such as streptococcal pharyngitis or syphilis, which are not the main problems of the toddler. The toddler has no signs of a bacterial infection, such as purulent discharge, foul odor, or localized inflammation.

Choice D reason: Topical hydrocortisone is not a helpful prescription, as it is used to treat skin conditions, such as eczema or dermatitis, which are not the main problems of the toddler. The toddler has a rash that is caused by the inflammation of the blood vessels, not by an allergic or irritant reaction. Topical hydrocortisone may also worsen the rash or cause skin thinning or infection.

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Which of the following findings should the nurse report to the health care provider immediately? (select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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