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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 A

Explanation

A. Obtain a blood culture. The first action is to obtain a blood culture to identify the causative organism before starting antibiotic therapy. This ensures that the appropriate antibiotic is selected.
B. Request a referral for physical therapy. Physical therapy may be needed later, but it is not the priority during admission.
C. Administer IV antibiotics. Antibiotics should be given after obtaining a blood culture to avoid altering the test results.
D. Record intake and output. While monitoring fluid balance is important, it is not the priority action during admission.

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

Explanation

Initiating airborne precautions. The child’s symptoms (fever, headache, nausea, lethargy, irritability, nuchal rigidity, and elevated WBC count) suggest bacterial or viral meningitis, which requires airborne precautions if tuberculosis or certain viral causes are suspected.

WBC. The child's WBC count is elevated (14,000 mm³), indicating a possible infection, which supports the need for precautions to prevent transmission.

Administering potassium chloride. The child's potassium level (3.8 mEq/L) is within the normal range (3.4-4.7 mEq/L), so potassium replacement is unnecessary.

Pain level. While pain management is important, it does not directly relate to the need for airborne precautions.

Administering acyclovir. Acyclovir is an antiviral used to treat herpes infections, but there is no indication in the scenario that the child has a viral infection requiring acyclovir.

Lymph node findings. While cervical lymphadenopathy can occur with infections, it does not necessarily indicate the need for acyclovir.

Increasing environmental stimuli. The child is already lethargic and irritable, so reducing stimuli (not increasing) would be more appropriate.

Potassium level. The potassium level is normal and does not indicate a need for intervention.

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