A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.
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.
Weight-bearing ability on the affected leg
Temperature
WBC count
Wound assessment
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I will monitor my child's blood glucose levels every 8 hours.": During illness, blood glucose can fluctuate rapidly due to stress hormones and changes in intake. Monitoring every 8 hours is not frequent enough; checks should be done every 3–4 hours or as recommended.
B. "I will increase the amount of fluids I offer my child.": Illness increases the risk of dehydration and ketoacidosis in children with diabetes. Encouraging extra fluids helps prevent dehydration and assists in flushing out ketones, making this an appropriate action.
C. "I will offer my child 20 grams of carbohydrates every 2 hours.": While carbohydrate intake is important when sick, strict scheduled dosing like this is not necessary unless blood glucose is low. Nutrition should be tailored to blood sugar levels and the child’s tolerance.
D. "I will withhold my child's dose of insulin when his appetite is poor.": Insulin should not be withheld during illness, even if the child eats less. The body may require the same or increased insulin due to stress hormones, and skipping doses raises the risk of hyperglycemia.
Correct Answer is D
Explanation
A. Desquamation: Skin peeling or desquamation is an acute side effect of radiation therapy, typically appearing during or shortly after treatment, not years later.
B. Nausea: Nausea is also an acute effect that commonly occurs during radiation therapy, especially when the gastrointestinal tract or brain is involved. It is not considered a late effect years after treatment.
C. Mucosal ulceration: Ulceration of the mucous membranes is an early complication related to radiation affecting rapidly dividing cells. It resolves after treatment and is not a late manifestation.
D. Short stature: Radiation therapy in young children can damage growth plates and affect hormone production, leading to growth delays and short stature. This is a recognized late adverse effect seen years after treatment.
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