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A nurse in the provider's office is assisting with the care of a child.

Exhibits

Upon review of the child's electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions? Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing due to .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Increased seizure activity

  • Finding: Phenytoin level

The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.

Pneumonia

  • Finding: Cough

 A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.

Liver failure

  • Finding: Skin rash

Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.

Steven-Johnson syndrome

  • Finding: Liver enzymes

Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.

Pneumothorax

  • Finding: Lung sounds

A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.


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Related Questions

Correct Answer is C

Explanation

Inject insulin in the deltoid muscle: Insulin is administered subcutaneously, not intramuscularly. Common sites for insulin injection include the abdomen, thighs, and upper arms.

B. Take glyburide with breakfast: Glyburide is an oral hypoglycemic agent used for type 2 diabetes, not type 1 diabetes. Adolescents with type 1 diabetes require insulin.

C. Obtain an influenza vaccine annually: People with diabetes are at higher risk for complications from influenza, so annual vaccination is recommended to prevent illness.

D. Administer glucagon for hyperglycemia: Glucagon is used to treat severe hypoglycaemia, not hyperglycaemia. For hyperglycemia, insulin administration and monitoring blood glucose levels are key.

Correct Answer is A

Explanation

A. Initiate droplet precautions. Pertussis (whooping cough) is transmitted via respiratory droplets. Droplet precautions are necessary to prevent the spread of the disease through coughs or sneezes.

B. Initiate a protective environment. A protective environment is used for patients with severe immunocompromised conditions to protect them from infections, not to prevent the spread of respiratory infections like pertussis.

C. Initiate contact precautions. Contact precautions are used for infections spread by direct or indirect contact with the patient or their environment, such as MRSA. Pertussis is spread by droplets, not by contact.

D. Initiate airborne precautions. Airborne precautions are for diseases that are spread through airborne particles, such as tuberculosis or measles. Pertussis is not airborne but spread through larger respiratory droplets.

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