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 identity as requiring immediate follow-up? Select the 5 findings that require immediate follow-up.
Abdominal assessment
Peripheral pulses
Pain assessment
Neurologic assessment
WBC
Hemoglobin
Glucose
Temperature
Correct Answer : B,C,D,F,H
A. Abdominal assessment: The child’s abdomen is flat, non-distended, and bowel sounds are active, which are expected findings. This does not require immediate follow-up.
B. Peripheral pulses: Radial and pedal pulses are 1+ bilaterally with delayed capillary refill of 4 seconds, suggesting poor perfusion and early shock. This requires prompt follow-up to prevent cardiovascular compromise.
C. Pain assessment: The child reports a severe headache (7/10), along with nausea and irritability. Combined with fever and nuchal rigidity, this pain points toward possible meningitis, making this a priority finding.
D. Neurologic assessment: Lethargy, irritability, agitation, and nuchal rigidity are concerning neurologic findings. These indicate possible central nervous system infection or increased intracranial pressure, requiring immediate provider notification.
E. WBC: A WBC count of 14,000/mm³ is elevated, suggesting infection. However, this is an expected finding given the clinical picture and does not require immediate intervention beyond the already ordered cultures and administration of antibiotics.
F. Hemoglobin: A hemoglobin of 9.5 g/dL is below normal, indicating anemia. In the context of tachycardia and poor perfusion, this may worsen oxygen delivery and requires provider follow-up.
G. Glucose: A glucose of 90 mg/dL is within normal limits for a child and does not require immediate follow-up.
H. Temperature: A fever of 38.7°C (101.7°F) is significant in combination with neurologic changes and petechiae, raising concern for meningitis or sepsis. This finding requires urgent follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Offer your child foods that are low in calories.": Children with cystic fibrosis require increased caloric intake due to higher metabolic demands and malabsorption issues. A low-calorie diet would not meet their energy needs and could lead to poor growth and nutritional deficits.
B. "Offer your child foods that are low in protein.": Protein is essential for growth, tissue repair, and immune function, especially in children with cystic fibrosis who experience chronic illness. Restricting protein would worsen nutritional deficiencies and impair development.
C. "Offer your child foods that are high in vitamin C.": While vitamin C is beneficial for immune support, the primary concern in cystic fibrosis is fat and fat-soluble vitamin malabsorption (A, D, E, and K). Simply increasing vitamin C intake does not adequately address nutritional needs.
D. "Offer your child foods that are high in fat.": High-fat foods are encouraged for children with cystic fibrosis because they provide dense calories needed to meet high energy requirements. With pancreatic enzyme replacement, fat absorption is improved, making this the most appropriate dietary recommendation.
Correct Answer is D
Explanation
A. "I will be excused from physical education class.": Physical activity is actually encouraged in adolescents with cystic fibrosis, as it helps improve lung function, mobilize secretions, and enhance overall health. Avoiding exercise would not support effective disease management.
B. "I will limit my calcium intake to prevent kidney stones.": Children with cystic fibrosis are at risk for osteoporosis due to malabsorption of fat-soluble vitamins and poor bone health, not kidney stones from calcium. Adequate calcium intake is essential for bone strength.
C. "I will take fewer enzymes when I eat high-fat foods.": Pancreatic enzymes should be taken with all meals and snacks, especially those high in fat, to aid in digestion and nutrient absorption. Taking fewer enzymes would worsen malabsorption and nutritional deficiencies.
D. "I will increase my intake of vitamin D.": Fat-soluble vitamin deficiencies, including vitamin D, are common in cystic fibrosis due to malabsorption. Supplementing vitamin D supports bone health and calcium absorption.
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