A nurse assisting with the care of a client who is admitted to the medical-surgical unit.

The nurse is reviewing the client's laboratory findings and vital signs.

Select the 5 findings that require immediate follow-up.

A) Request an x-ray of the neck: In cases of suspected epiglottitis, a lateral neck x-ray can help confirm the diagnosis by showing the classic "thumbprint sign," which indicates swelling of the epiglottis. This is a critical diagnostic step, but it should only be performed in a controlled setting where the child’s airway can be monitored closely. The priority is to avoid any procedures that may cause irritation or further compromise the airway.

B) Monitor urine for protein: Monitoring urine for protein is not relevant to the management of epiglottitis. This condition is related to inflammation and obstruction of the upper airway, and the focus should be on respiratory management rather than renal function.

C) Obtain a nasopharyngeal swab: While obtaining a nasopharyngeal swab can help identify the organism causing an infection (often bacterial), it is not the immediate priority in a child with suspected epiglottitis. The child’s airway is the most critical concern, and diagnostic interventions that could potentially cause further distress or obstruction (such as swabbing) should be avoided until airway management is stable.

D) Administer fluconazole: Fluconazole is an antifungal medication, and its use is not appropriate for epiglottitis. Epiglottitis is most often caused by a bacterial infection, particularly Haemophilus influenzae type b (Hib), which requires antibiotic therapy, not antifungals.

Fear of abandonment: Clients with borderline personality disorder (BPD) often have an intense fear of abandonment, leading to unstable relationships and emotional outbursts. The client’s fluctuating behavior towards the nurse (from anger to admiration) suggests this pattern.

Emotional instability: BPD is characterized by rapid mood changes and intense emotional reactions. The client displays aggression, impulsivity, and mood shifts, as seen in their outbursts and sudden praise for the nurse.

Incorrect:

Elevated body temperature: Fever is not a characteristic of BPD. It is more commonly associated with infections or inflammatory conditions.

Tactile hallucinations: Hallucinations are more common in psychotic disorders or substance withdrawal rather than BPD.

Increased heart rate: Tachycardia is a physiological response to stress, anxiety, or substance use but is not a defining feature of BPD.