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: 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.

A. This test will confirm if your child had a recent streptococcal infection. B. This test will indicate if your child has rheumatic fever. C. This test will confirm if your child has immunity to streptococcal bacteria. D. This test will indicate if your child has a therapeutic blood level of an aminoglycoside.

Correct Answer is A

Explanation

Choice A reason: This test measures the level of antibodies that the body produces against the streptolysin O enzyme, which is produced by some strains of streptococcal bacteria. A high level of ASO titer indicates that the child had a recent streptococcal infection, which may trigger rheumatic fever in some cases.

Choice B reason: This test does not directly indicate if the child has rheumatic fever. Rheumatic fever is a complication of untreated or inadequately treated streptococcal infection, which causes inflammation of the heart, joints, skin, and brain. The diagnosis of rheumatic fever is based on clinical criteria, such as the presence of carditis, polyarthritis, chorea, erythema marginatum, or subcutaneous nodules.

Choice C reason: This test does not confirm if the child has immunity to streptococcal bacteria. Immunity is the ability of the body to resist or fight off an infection. A high level of ASO titer does not mean that the child is immune to streptococcal bacteria, but rather that the child was exposed to them recently.

Choice D reason: This test does not indicate if the child has a therapeutic blood level of an aminoglycoside. Aminoglycosides are a class of antibiotics that are used to treat serious bacterial infections, such as endocarditis or septicemia. The blood level of an aminoglycoside is measured by a different test, called a peak and trough level, which determines the effectiveness and safety of the drug.

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

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching?

Correct Answer is D

Explanation

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an antistreptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse give?

Correct Answer is A

Explanation

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