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Rationale for correct choices:

• Spontaneous abortion: The client is at risk of a spontaneous abortion, as evidenced by bright red vaginal bleeding, cramping, and an open cervix at 10 weeks gestation. These findings are classic for an inevitable abortion, particularly when fetal viability has not been confirmed and symptoms are active.
• Cervical dilation: Cervical dilation during the first trimester, especially in conjunction with vaginal bleeding and uterine cramping, confirms that the miscarriage process is in progress. In a viable pregnancy, the cervix remains closed, so dilation is a key indicator of pregnancy loss.

Rationale for incorrect choices:

• Molar pregnancy: While molar pregnancies can cause elevated hCG levels, they typically present with painless bleeding, absence of a fetus on ultrasound, and may show signs like early-onset preeclampsia or hyperemesis. The presence of pain and cervical dilation points away from a molar pregnancy.
• Ectopic pregnancy: An ectopic pregnancy more often presents with sharp unilateral lower abdominal pain, low or slowly rising hCG levels, and an empty uterus on ultrasound. The findings of cervical dilation and an hCG level consistent with intrauterine pregnancy reduce the likelihood of an ectopic pregnancy.
• Bright red vaginal bleeding: Although bright red bleeding suggests active hemorrhage and is concerning, it can occur in a variety of obstetric conditions. Without cervical dilation or signs of fetal compromise, it cannot alone confirm spontaneous abortion.
• History of chlamydia infection: While a history of chlamydia increases the risk of ectopic pregnancy due to tubal scarring, it is not a direct indicator of current pregnancy loss. It does not outweigh the importance of current symptoms like cervical dilation in determining the client's current risk.

Rationale for correct choices:

• Opioid intoxication: The client's decreased respiratory rate, drowsiness, pinpoint pupils, and positive response to naloxone are all indicative of opioid intoxication. These features, along with the presence of a needle in the antecubital space, strongly support recent opioid use and CNS depression.
• Pupil characteristics: Miotic pupils, or pinpoint pupils, are a classic physical sign of opioid intoxication. They occur due to opioid stimulation of the parasympathetic nervous system, and in a sedated client with a history of injection drug use, they confirm the likelihood of opioid overdose.

Rationale for incorrect choices:

• Alcohol intoxication: Alcohol intoxication usually presents with disinhibition, unsteady gait, slurred speech, and potentially aggressive or inappropriate behavior. The client’s severe sedation, low respiratory rate, and constricted pupils are not typical features of alcohol intoxication, especially with only one beer reported.
• Alcohol withdrawal: Alcohol withdrawal manifests with symptoms like tremors, agitation, hallucinations, seizures, and autonomic instability (tachycardia, hypertension). This client is sedated with bradypnea and hypotension, which are incompatible with alcohol withdrawal and more suggestive of CNS depression.
• Opioid withdrawal: Opioid withdrawal is marked by agitation, anxiety, mydriasis, vomiting, diarrhea, and piloerection. In contrast, this client is drowsy, has decreased bowel sounds, and constricted pupils, pointing toward active opioid intoxication rather than withdrawal.
• Amount of alcohol consumed: The report from EMS indicates the client consumed only one beer, which is insufficient to explain the severity of the symptoms. Minimal alcohol intake also makes both intoxication and withdrawal from alcohol highly unlikely as the primary issue.
• Current temperature: The client’s current temperature of 37.2°C (99°F) is within normal limits and does not support any particular diagnosis. It neither confirms nor excludes opioid or alcohol intoxication or withdrawal and is not a defining clinical sign in this context.
• Breath sounds: Breath sounds are equal and clear, offering no abnormal findings to support or contradict a diagnosis. While important for general assessment, they are not specific indicators for opioid intoxication or withdrawal and thus are less relevant than pupil changes.

Rationale for correct choices:

• Pneumonia: The child is at risk for pneumonia, a common postoperative complication in pediatric clients, particularly after abdominal surgery. The presence of shallow breathing, refusal to use the incentive spirometer, and slight decrease in breath sounds at the bases suggest poor lung expansion and secretion stasis, increasing the risk of atelectasis and secondary infection.
• Shallow breathing: Shallow breathing is likely due to pain and limited movement of the diaphragm after abdominal surgery. It reduces alveolar ventilation, promoting hypoventilation and mucus retention, which predisposes the lungs to infection and the development of postoperative pneumonia.
• Lack of incentive spirometer use: Incentive spirometry is essential for preventing postoperative pulmonary complications by encouraging deep breathing and lung expansion. The child’s ongoing refusal to use the spirometer further increases the risk of pneumonia by allowing mucus to accumulate in the lungs, especially when combined with shallow breathing.

Rationale for incorrect choices:

• Peritonitis: Peritonitis would likely present with a rigid abdomen, high fever, worsening or spreading pain, and systemic signs of infection. While the child has abdominal tenderness, the dressing remains dry and intact, bowel sounds are absent but stable, and there is no significant fever or signs of sepsis, making peritonitis less likely.
• Wound infection: Wound infection would manifest as redness, swelling, purulent drainage, or increased warmth at the surgical site. The child’s dressing is consistently dry and intact throughout the day, with no signs of wound disruption or local infection noted in the nurse’s documentation.
• Bowel sounds: Absent bowel sounds are expected after abdominal surgery and may persist for 24–72 hours. While this finding warrants monitoring, it is not directly linked to pneumonia and is better associated with risks like postoperative ileus or delayed gastrointestinal recovery.
• Temperature: The child’s temperature remains below the threshold of 38.5°C and has only minimally increased from 37.0°C to 37.7°C throughout the day. This mild elevation is not specific to indicate infection and does not confirm a risk of pneumonia or other systemic complications.
• Surgical dressing: The surgical dressing remains dry and intact with no signs of leakage or infection. This finding suggests appropriate healing at the incision site and does not indicate any direct complication such as pneumonia or wound infection.
• Abdominal tenderness: Although abdominal tenderness has increased slightly, it is still expected in the postoperative period. Without signs of peritoneal inflammation or wound infection, this symptom alone does not confirm a complication and is more reflective of localized surgical pain.

Rationale:

• Drooling: Drooling is classic in epiglottitis due to severe throat pain and an inability to swallow. It is not commonly seen in RSV or streptococcal pharyngitis, where swallowing remains relatively intact.
• Hypoxia: Both epiglottitis and RSV can cause hypoxia. In epiglottitis, airway obstruction can quickly compromise oxygenation. In RSV, hypoxia results from inflammation and mucus plugging in the small airways.
• Fever: Fever is a nonspecific but common finding across all three conditions. It signals an inflammatory or infectious process, whether viral (RSV), bacterial (Streptococcus), or in epiglottitis (often Haemophilus influenzae type b if unimmunized).
• Tachypnea: Tachypnea may occur in both epiglottitis and RSV as the body compensates for airway compromise and impaired gas exchange. It is not a typical feature of uncomplicated streptococcal pharyngitis.
• Exudate on pharynx: Pharyngeal exudates are common in streptococcal pharyngitis and help differentiate it from viral causes. They are typically absent in RSV and epiglottitis, where the pathology lies elsewhere (lower airways or supraglottic structures).
• Wheezing upon auscultation: Wheezing is a hallmark of RSV due to bronchiolar inflammation and narrowing. It is not seen in epiglottitis or streptococcal pharyngitis, as those conditions do not primarily affect the bronchioles.

Rationale:

• Temperature: The child’s temperature is 37.4°C (99.3°F), which is mildly elevated. Crohn’s disease typically causes intermittent fever during flare-ups. Appendicitis often presents with a higher fever in later stages. Intussusception can cause low-grade fever due to bowel inflammation, making it the most consistent with this finding.
• Vomiting: Vomiting is uncommon in Crohn’s disease unless there’s obstruction or severe disease. In appendicitis, vomiting usually follows the onset of pain and is related to peritoneal irritation. Intussusception often involves vomiting early due to intermittent bowel obstruction, making it consistent with this client’s symptoms.
• Abdominal findings: Crohn’s disease rarely produces a palpable abdominal mass or sudden distension. Appendicitis can cause right-sided tenderness and decreased bowel sounds but does not typically involve a mass. Intussusception often presents with a distended abdomen, hypoactive bowel sounds, and a sausage-shaped mass in the right upper quadrant, as described.
• Stool: Crohn’s disease can lead to bloody, mucus-filled stools due to ulceration in the intestinal lining. Appendicitis does not typically alter stool characteristics unless perforation occurs. Intussusception is well known for producing “currant jelly” stools, composed of blood and mucus, aligning with this child’s bowel movement description.
• Pain rating: A FLACC score of 5 indicates moderate pain. Crohn’s pain tends to be chronic and crampy rather than episodic. Appendicitis pain worsens over time and becomes localized, typically in the right lower quadrant. Intussusception causes intermittent, severe abdominal pain with sudden relief, matching the child’s pain episodes and behavior.

Rationale for correct choices:

• A change in mood: Mood changes, including depression, irritability, or suicidal thoughts, are serious adverse effects associated with isotretinoin use. Adolescents are particularly vulnerable to these side effects, and any mood alterations during treatment warrant immediate provider notification.
• Decreased night vision: Isotretinoin can lead to visual disturbances, including decreased night vision, which may be sudden and irreversible. This adverse effect is rare but serious, and any signs of visual impairment should be reported promptly to prevent injury or permanent damage.

Rationale for incorrect choices:

• The development of dry eyes: Dry eyes are a common and expected side effect of isotretinoin, often due to mucous membrane dryness. While uncomfortable, it is not typically dangerous and can usually be managed with lubricating eye drops or supportive care without immediate provider contact.
• Dry mouth: Dry mouth occurs frequently with isotretinoin due to its drying effects on mucosal surfaces. It is bothersome but not dangerous, and clients can manage it with increased fluid intake and sugar-free lozenges. It doesn’t require urgent medical attention unless severe.
• Nausea: Nausea is not a common or concerning side effect of isotretinoin. If persistent or severe, it may require evaluation, but it is not a priority symptom for immediate provider contact unless accompanied by other warning signs like abdominal pain or jaundice.
• Sunburn: Increased photosensitivity is an expected effect of isotretinoin, and clients should be advised to wear sunscreen and protective clothing. Sunburn, while uncomfortable, is not an emergency and does not require immediate medical consultation unless it becomes severe.
• Worsening of acne: An initial acne flare is a known and expected part of isotretinoin therapy as pores begin to purge. This typically improves after several weeks and does not indicate treatment failure or require immediate provider notification unless accompanied by signs of infection.
• Engagement in sexual activity: While not a symptom, sexual activity is significant for female clients due to isotretinoin's teratogenicity. However, since this client has a negative hCG and is not sexually active, this is part of routine risk counselling not an immediate concern unless pregnancy is possible.

Rationale:

• Monitor for elevated temperature: Epidural anesthesia can mask symptoms of infection such as chorioamnionitis. Monitoring temperature helps detect early signs of infection or epidural-related complications.
• Assess for urinary retention: Epidural anesthesia often causes loss of bladder sensation, increasing the risk for urinary retention. Regular assessments are needed to determine when catheterization is required.
• Assist the client with ambulation: After epidural anesthesia, lower limb motor function may be impaired. Ambulation is unsafe due to the risk of falls and injury; bedrest is generally advised until full motor function returns.
• Inform the client to expect drowsiness: Drowsiness is not a typical side effect of epidural anesthesia; it may indicate systemic absorption or another issue. Encouraging drowsiness may mask concerning symptoms that need prompt evaluation.
• Encourage the client to turn from side to side: Repositioning helps maintain optimal uteroplacental perfusion and prevents hypotension caused by vena cava compression from aortocaval syndrome.