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• WBC count: The WBC count increased from 14,000 to 15,000/mm³, indicating a persisting or intensifying systemic inflammatory response. This could reflect an ongoing or worsening infection despite treatment and warrants continued monitoring.
• Temperature: The adolescent’s temperature decreased from 38.8°C to 37.6°C, indicating reduced systemic inflammatory response and a likely response to antibiotic therapy.
• Wound assessment: The area of induration decreased from 6 x 6 cm to 5 x 5 cm, suggesting local improvement in inflammation and effectiveness of treatment.
• Weight-bearing ability on affected leg: The adolescent was able to ambulate twice and tolerated it well, suggesting reduced pain, improved mobility, and stabilization of the local infection.

• Pelvic Inflammatory Disease (PID): The client’s mucopurulent cervical discharge, pelvic pain, recent multiple sexual partners, fever, and urinary discomfort point strongly toward PID, a common infection of the upper genital tract in sexually active adolescents.
• Administer acetaminophen 650 mg PO every 6 hr PRN pain: Acetaminophen is appropriate for managing PID-associated fever and cramping pain without interfering with diagnostic assessments.
• Place the adolescent on bedrest in semi-Fowler's position: Semi-Fowler's positioning facilitates pelvic drainage, reduces the risk of abscess formation, and supports comfort.
• Temperature greater than 38.3°C (100.9°F): Ongoing fever indicates systemic infection or lack of response to treatment, making it a key marker for disease progression or resolution.
• Vaginal bleeding: Monitoring for abnormal bleeding is important, as PID can involve endometrial inflammation or complications like ectopic pregnancy or miscarriage if not promptly managed.

Rationale for Incorrect Choices:

• Urinary tract infection: UTIs typically cause dysuria, frequency, and suprapubic pain, but PID presents with more systemic symptoms and pelvic tenderness, along with sexual history risk factors.
• Ectopic pregnancy: Though a possibility, the client recently had her period 7 days ago, making active ectopic pregnancy less likely; there is also no mention of missed periods or positive pregnancy test.
• Acute appendicitis: This usually involves right lower quadrant pain and rebound tenderness; cervical discharge and bilateral pelvic pain make PID more likely.
• Instruct the adolescent about the use of sitz baths: Sitz baths help with localized perineal discomfort but are not primary management for PID.
• Administer an enema: This is unrelated to PID and could worsen abdominal discomfort or cause unnecessary complications.
• Maintain an NPO status: NPO is reserved for surgical cases or procedures requiring sedation; PID is typically managed with medications and does not require dietary restrictions.
• Rebound tenderness: While it can indicate peritonitis as a result of peritoneal irritation, it's more typical of appendicitis than PID.
• Presence of a Cullen’s sign: Cullen’s sign (periumbilical bruising) is associated with intra-abdominal bleeding such as pancreatitis or ruptured ectopic pregnancy, not PID.
• Irritation of the phrenic nerve: This is associated with upper abdominal pathology like gallbladder disease, not with PID.

• IV hydromorphone: This potent opioid analgesic is indicated for managing severe pain during vaso-occlusive crises in sickle cell disease, especially when pain reaches a level of 10/10 despite prior interventions. Rapid IV delivery ensures quicker pain relief.
• Pain: The child’s reported pain escalation from 7 to 10 out of 10, along with swelling and warmth of the knee, strongly indicates severe vaso-occlusive pain, which is a hallmark of sickle cell crisis requiring urgent analgesic management.

Rationale for Incorrect Choices:

• Oxygen at 2 L/min via nasal cannula: The child’s oxygen saturation remains normal at 96% on room air, indicating no current hypoxia. Supplemental oxygen is not necessary unless oxygen saturation drops or respiratory distress develops.
• Oral amoxicillin: There are no clinical signs or lab evidence of infection (e.g., normal WBC count, no fever), so antibiotics are not warranted. Prophylactic antibiotics may be used in certain sickle cell scenarios but are not indicated here.
• Hypoxia: The child maintains normal oxygenation, making hypoxia an unlikely contributing factor to the current presentation. Hypoxia would require both clinical signs (e.g., low SpO₂) and symptoms like shortness of breath.
• Signs of infection: The absence of fever, normal WBC count, and localized pain without erythema or drainage suggest that infection is not present at this time. Pain is due to vaso-occlusion, not infectious origin.

• Capillary refill 4 seconds: Prolonged capillary refill indicates poor peripheral perfusion, often due to dehydration or shock in toddlers. This requires urgent assessment and intervention to prevent further circulatory compromise.
• Extremities cool: Cool extremities suggest vasoconstriction caused by decreased circulating volume or shock. Immediate evaluation is necessary to prevent progression of hypovolemia.
• Reports no tears: Lack of tears while crying is a hallmark sign of moderate to severe dehydration, signaling the need for urgent fluid replacement therapy.
• Lethargic: Lethargy reflects altered mental status and possible systemic compromise, requiring immediate medical evaluation to address underlying causes such as severe dehydration or infection.
• Hyperactive bowel sounds: Hyperactive bowel sounds correlate with diarrhea and fluid loss, which can worsen dehydration. Prompt monitoring and management are necessary to prevent complications.

Rationale for Incorrect Choices:

• Respiratory rate 26/min: This respiratory rate falls within the normal toddler range (20–30/min) and does not indicate respiratory distress or need for urgent intervention.
• Heart rate 112/min: A mild tachycardia can be expected in a toddler with mild dehydration or distress but is not an isolated sign of immediate concern.
• Diaper area reddened: Diaper rash is a common irritation due to frequent stools and requires routine skin care, not urgent clinical action unless worsened.