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A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.

Exhibits

The nurse is assessing the adolescent 24 hr after the initial visit. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition. There must be at least 1 selection in every row. There does not need to be a selection in every column.

A.

Weight-bearing ability on the affected leg

B.

Temperature

C.

WBC count

D.

Wound assessment

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Rationale:

• Weight-bearing ability on the affected leg: The adolescent was able to ambulate in the hall twice with good tolerance, which suggests improved mobility despite persistent tenderness. This indicates that pain and function are gradually improving.

• Temperature: The fever decreased from 38.8°C on Day 1 to 37.6°C on Day 2, showing resolution of the systemic response to infection. This suggests the antibiotic therapy is beginning to take effect.

• WBC count: The count rose from 14,000/mm³ to 15,000/mm³ in 24 hours, which reflects a persistent or worsening inflammatory and infectious process. This indicates the infection may not yet be under control.

• Wound assessment: The indurated area on the calf decreased in size from 6 x 6 cm on Day 1 to 5 x 5 cm on Day 2. A decrease in the size of the inflamed area indicates that the cellulitis is responding to treatment and resolving.


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Related Questions

Correct Answer is B

Explanation

A. Initiate airborne precautions: Airborne precautions are not required for a child receiving gentamicin, as this antibiotic is not used for airborne infections such as tuberculosis or measles. Standard precautions are sufficient.

B. Maintain strict I&O: Gentamicin is nephrotoxic, and monitoring intake and output is essential to detect early signs of kidney impairment. Strict fluid balance assessment helps ensure prompt recognition of adverse renal effects.

C. Monitor for constipation: Constipation is not a typical adverse effect of gentamicin therapy. More concerning effects are nephrotoxicity and ototoxicity, which require close monitoring during treatment.

D. Encourage bed rest: Bed rest is not necessary during gentamicin therapy. Activity restrictions are not required unless dictated by the child’s underlying illness or other clinical factors.

Correct Answer is A

Explanation

A. 1 cup raw broccoli: Broccoli is a lactose-free vegetable that provides a good source of calcium, making it an excellent option for children with lactose intolerance who need to maintain bone health.

B. One slice white bread: White bread provides only minimal calcium, unless fortified, and does not contribute significantly to daily calcium requirements. It is not considered a reliable source of calcium.

C. 2 tbsp peanut butter: Peanut butter contains protein and some minerals, but it is low in calcium. It cannot meet the nutritional needs for bone development in children with lactose intolerance.

D. One poached egg: Eggs provide protein and other nutrients but very little calcium. They are not a suitable substitute for maintaining adequate calcium intake.

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