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A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.

Temperature

Sclera

Bowel sounds

Abdominal tenderness

Anorexia

Breath sounds

Heart rate

Skin

Answer and Explanation

Correct Answer : B,D,E,G,H

Temperature: A temperature of 37.5° C (99.5° F) is within the normal to slightly elevated range and is not high enough to be classified as fever. Therefore, it does not require immediate reporting unless accompanied by other signs of infection or systemic illness.
Sclera: Yellow-tinged sclera suggests jaundice, indicating possible liver dysfunction, which could be related to substance use or hepatitis. Jaundice is a significant clinical finding that requires immediate provider notification for further evaluation and management.
Bowel sounds: Hyperactive bowel sounds are a non-specific finding and can result from gastrointestinal irritation, substance use, or stress. Alone, they do not warrant urgent reporting unless accompanied by more serious signs like severe pain or vomiting.
Abdominal tenderness: Epigastric tenderness could suggest gastrointestinal complications such as hepatitis, pancreatitis, or gastritis, especially in the context of drug use. Abdominal pain on palpation is a concerning symptom that must be reported for further diagnostic workup.
Anorexia: Significant anorexia along with nausea, vomiting, and substance use points to potential systemic illness or gastrointestinal involvement. In adolescents, persistent anorexia is a warning sign that needs prompt evaluation to prevent nutritional deficiencies and worsening health.
Breath sounds: Clear breath sounds are a normal finding and do not require immediate provider notification. There are no respiratory concerns indicated by the lung assessment provided in the notes.
Heart rate: A heart rate of 103/min indicates mild tachycardia, which could be due to dehydration, substance use, or an underlying systemic condition. Tachycardia should be reported to assess if immediate interventions like fluid replacement are necessary.
Skin: Dry skin with poor turgor signals dehydration, a critical finding especially with the reported vomiting and drug use. Dehydration can rapidly worsen and must be addressed by the provider for fluid management and further care.

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Correct Answer is B

Explanation

A. Hypertension: Hyponatremia typically leads to hypotension due to fluid shifts out of the vascular space rather than hypertension, especially if it is associated with hypovolemia. Low sodium levels can reduce blood volume and pressure, making hypertension an unlikely finding in this condition.

B. Muscle cramps: Muscle cramps are a common symptom of hyponatremia due to disrupted electrolyte balance affecting neuromuscular function. Low sodium levels impair muscle contraction and nerve signal transmission, leading to cramps, weakness, and fatigue.

C. Blurred vision: Blurred vision is not a typical manifestation of hyponatremia. While severe hyponatremia can cause neurological symptoms like confusion or seizures, visual disturbances like blurred vision are not primary signs linked to sodium imbalance.

D. Constipation: Constipation is more often associated with dehydration, immobility, or other electrolyte imbalances such as hypercalcemia. Hyponatremia primarily affects neuromuscular and central nervous system function rather than gastrointestinal motility.

A. "Check the water temperature with your finger" B. "Hold your baby under running water when washing his hair," C. "Cleanse the eyes from the inner canthus outward. D. "Set the water heater to 125.6 degrees Fahrenheit."

Correct Answer is C

Explanation

A. "Check the water temperature with your finger": Checking water temperature with a finger is unreliable because fingers may tolerate higher temperatures without discomfort. It is recommended to use the inside of the wrist or a thermometer to ensure the water is warm but not hot, typically around 100°F (37.8°C), to prevent burns.

B. "Hold your baby under running water when washing his hair": Holding a newborn under running water is unsafe because it can cause sudden chilling, difficulty breathing, or even slipping. Instead, caregivers should use a damp, warm washcloth or gently pour water over the baby's head while securely supporting it.

C. "Cleanse the eyes from the inner canthus outward": Cleaning from the inner to the outer canthus is correct technique because it prevents introducing contaminants into the tear duct. This motion also minimizes the spread of bacteria, reducing the risk of eye infections in the delicate eyes of a newborn.

D. "Set the water heater to 125.6 degrees Fahrenheit": A water heater set to 125.6°F presents a high risk of scald burns in infants. Safety guidelines recommend setting the water heater to no higher than 120°F (48.9°C) to reduce the risk of accidental burns during bathing or household water use.

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A nurse is assisting in the care of an adolescent. The nurse is reviewing the data collection findings. Select the 5 findings the nurse should report to the provider.

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A nurse is assisting in the care of an adolescent.

The nurse is reviewing the data collection findings.

Select the 5 findings the nurse should report to the provider.