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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.


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    Related Questions

    Correct Answer is D

    Explanation

    A. Regular diet, no added salt: A regular diet with no added salt does not adequately address the sodium restriction needed to manage edema in acute glomerulonephritis.
    B. Low-carbohydrate, low-protein diet: Restricting carbohydrates and proteins is not typically necessary in acute glomerulonephritis unless there are specific complications.
    C. Low-protein, low-potassium diet: While protein restriction may be necessary in chronic kidney disease, it is not typically the primary focus in managing acute glomerulonephritis.
    D. Low-sodium, fluid-restricted: A low-sodium diet helps to reduce fluid retention and manage edema in acute glomerulonephritis. Fluid restriction may also be necessary to manage fluid balance.

    Correct Answer is ["C","D","E"]

    Explanation

    A. Excessive hair growth: Hair loss, not excessive hair growth, is a common side effect of chemotherapy.
    B. Increased appetite. Chemotherapy often causes nausea, vomiting, and reduced appetite, not an increase in appetite.
    C. Fatigue. Fatigue is a common side effect of chemotherapy due to its impact on the body, including reduced blood counts and overall systemic stress.
    D. Possible infections: Chemotherapy weakens the immune system, increasing the risk of infections. The nurse will monitor the child for signs of infection and implement measures to prevent them, like proper hand hygiene and maintaining a clean environment.
    E. Easy bruising: Chemotherapy can affect blood clotting, making the child more susceptible to bruising. The nurse will educate the parents and child about precautions to minimize bruising risks

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