How it Works
Try Naxlex NCLEX-RN (Free-Trial)

A nurse is assisting in the care of a toddler.

Exhibits

A nurse is assisting in the care of a client. Complete the following sentence by using the list of options.

The nurse should first address the child's

followed by the child's .
Answer and Explanation

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

    Immediate priority: The child is febrile (38.9°C) with tachycardia. Fever and low Hgb and platelets suggest possible serious underlying hematologic disorder (e.g., leukemia, bone marrow suppression). Infection is life-threatening in this context. So temperature (fever) should be addressed first. Next concern: The lab values (low Hgb, Hct, platelets) show significant hematologic abnormalities that explain the fatigue, bruising, and petechiae and will guide further treatment (possible transfusion, infection risk management). Incorrect answers:
  • Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
  • Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
  • Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.
  • Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.
  • Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.
  • Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.


    • Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

    Naxlex Comprehensive Predictor Exams

    Free Nursing Study Resources

    Related Questions

    Correct Answer is B

    Explanation

    A. Maculopapular lesions behind the ears: Maculopapular lesions are not characteristic of head lice infestation.
    B. White sacs attached to the hair shafts in the occipital area: White sacs (nits) attached to hair shafts are characteristic of head lice infestation.
    C. White flaky particles throughout the entire scalp region: White flaky particles are more suggestive of dry scalp or dandruff, not head lice.
    D. Lesions in the scalp that extend to the hairline or neck: Lesions extending to the hairline or neck could indicate secondary infection but are not specific to head lice infestation.

    Correct Answer is C

    Explanation

    A. "Give your infant an oral rehydration solution." While rehydration is important, projectile vomiting could indicate a more serious underlying issue that needs medical evaluation.
    B. "You might want to try switching to a different formula." Formula intolerance is less likely to cause projectile vomiting. A change in formula should not be suggested without ruling out more serious conditions first.
    C. "Bring your infant into the clinic today to be seen." Projectile vomiting in an infant, especially when followed by hunger, can indicate pyloric stenosis, a condition that requires prompt medical evaluation. The infant should be seen by a healthcare provider to determine the cause and initiate appropriate treatment.
    D. "Burp your child more frequently during feedings." Burping can help with regular gas and minor feeding issues, but it is unlikely to resolve projectile vomiting.

    Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

    Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

    Register