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A nurse is admitting an 8-year-old child to the pediatric unit.

A nurse is reviewing the child's electronic medical record (EMR). Which of the following findings should the nurse identify as requiring immediate follow-up? Select the 5 findings that require immediate follow-up.

A.

Neurologic assessment

B.

Hemoglobin

C.

Peripheral pulses

D.

WBC

E.

Glucose

F.

Abdominal assessment

G.

Pain assessment

H.

Temperature

Answer and Explanation

Correct Answer : A,B,D,F,H

A. Neurologic assessment. Neurologic changes can indicate worsening infection, sepsis, or other serious conditions, requiring immediate follow-up.

B. Hemoglobin. The child's hemoglobin level (9.5 g/dL) is below the normal range (10 to 15.5 g/dL), indicating anemia, which requires monitoring and possible intervention.

C. Peripheral pulses. There is no indication of circulatory compromise or perfusion issues in the given data.

D. WBC. The elevated WBC count (14,000 mm³) suggests an active infection or inflammation, which requires immediate follow-up.

E. Glucose. The glucose level (90 mg/dL) is within normal limits and does not require immediate attention.

F. Abdominal assessment. If the child has an infection, especially a serious bacterial infection, monitoring for abdominal distension, tenderness, or signs of peritonitis is crucial.

G. Pain assessment. While pain assessment is always important, it does not require immediate follow-up unless there are specific pain-related concerns in the provided data.

H. Temperature. Fever is a key sign of infection. Monitoring the child’s temperature is crucial in identifying worsening infection or sepsis.


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Related Questions

Correct Answer is C

Explanation

A. "You will need to give your child a course of corticosteroids." Corticosteroids are not used to treat scabies. Treatment involves topical permethrin cream or oral ivermectin, not steroids.
B. "Your entire home will need to be thoroughly cleaned." While cleaning bedding, clothing, and personal items is important, a full deep-cleaning of the home is not necessary because mites do not survive long away from human skin.
C. "Any person who has been in close contact with the child needs treatment." Scabies is highly contagious, and all household members and close contacts should be treated simultaneously to prevent reinfestation.
D. "Place your nonwashable items in sealed plastic bags for up to 5 days." Scabies mites can survive off the body for up to 3 days, so items should be bagged for at least 3 days, not 5.

Correct Answer is B

Explanation

A. "The blood pressure medicine I'm taking will help to keep my insulin level low." This is incorrect. Blood pressure medications do not regulate insulin levels.
B. "I will increase my food intake before I exercise." Exercise can lower blood glucose levels, increasing the risk of hypoglycemia. Eating a snack before exercise helps prevent this.
C. "As long as I take my insulin, I can eat whatever I want." Proper dietary management is essential in diabetes to maintain stable blood glucose levels.
D. "As I get older, my sugar levels will automatically decrease." Blood glucose levels require active management and do not decrease automatically with age.

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