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A nurse is caring for a 10-year-old male child.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body system

Findings

Neurological

Generalized muscle weakness noted in bilateral lower extremities.

Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10.

Patellar deep tendon reflexes 1+ bilaterally.

Child is awake and alert, responds appropriately to questions.

Gastrointestinal

Abdomen slightly firm, bowel sounds hypoactive.

Reports last bowel movement was 3 days ago.

Generalized muscle weakness noted in bilateral lower extremities

Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10

Abdomen slightly firm, bowel sounds hypoactive

Reports last bowel movement was 3 days ago

Child is awake and alert, responds appropriately to questions

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Findings that require immediate follow-up:

Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.

Findings that do not require immediate follow-up:

Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Koplik spots: These are small, white lesions on the buccal mucosa associated with measles, not meningitis.
B. Decreased protein in cerebrospinal fluid (CSF): Viral meningitis typically causes normal or slightly elevated protein levels in CSF.
C. Nuchal rigidity. Nuchal rigidity (stiff neck) is a classic sign of meningitis due to inflammation of the meninges.
D. Decreased glucose in cerebrospinal fluid: Decreased glucose in CSF is associated with bacterial meningitis, not viral.

A. "I will take my child's rectal temperature daily." B. "I will make sure to inspect my child's mouth every day for sores." C. "I will make sure my child gets their MMR vaccine this week." D. "I will ensure my child exercises a little each day by riding their bicycle."

Correct Answer is B

Explanation

A. "I will take my child's rectal temperature daily.": Taking a rectal temperature in a child receiving chemotherapy is not recommended because it increases the risk of rectal injury and infection. An oral or axillary temperature is preferred.
B. "I will make sure to inspect my child's mouth every day for sores." Chemotherapy suppresses the immune system, leaving the child vulnerable to infections such as mucositis. Inspecting the mouth daily is crucial to detect any sores or signs of infection early and prevent complications.
C. "I will make sure my child gets their MMR vaccine this week.": Live vaccines like the MMR (measles, mumps, rubella) vaccine should not be given during chemotherapy or other forms of immunosuppressive treatment.
D. "I will ensure my child exercises a little each day by riding their bicycle.": Exercise may be limited during chemotherapy due to fatigue and increased susceptibility to infection. Physical activity should be tailored to the child's ability and energy level, not mandated.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 3-year-old child who has viral meningitis. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to the parent of a 5-year-old child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

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