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.
Temperature
WBC count
Weight-bearing ability on the affected leg
Wound assessment
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Temperature: The temperature decreased from 38.8° C (101.8° F) to 37.6° C (99.7° F), which indicates a potential improvement in the infection response as the body temperature is coming down.
WBC count: The WBC count increased slightly from 14,000/mm³ to 15,000/mm³, which is still elevated compared to the normal range (5,000 to 10,000/mm³). This suggests that the body is still responding to infection and could indicate a worsening condition if the trend continues or remains elevated.
Weight-bearing ability on the affected leg: The improvement in weight-bearing ability suggests that the condition of the leg is improving. This indicates that the condition is improving as the pain or swelling may have decreased.
Wound assessment: The wound culture is still pending, and although there is no specific description provided, a pending culture and the general condition of the wound (which can be assessed for redness, warmth, or exudate) might still indicate a worsening condition if there is continued inflammation or signs of spreading cellulitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Lymphadenopathy. While some viral infections cause lymph node swelling, lymphadenopathy is not a hallmark sign of rubeola (measles).
B. Steatorrhea. Steatorrhea (fatty stools) is associated with conditions like cystic fibrosis and celiac disease, not rubeola.
C. Koplik spots. Koplik spots are small, white lesions with a red base found on the buccal mucosa, and they are a classic early sign of measles (rubeola).
D. Paroxysmal coughing. Paroxysmal coughing is characteristic of pertussis (whooping cough), not rubeola.
Correct Answer is A
Explanation
A. "Keep the car seat in a rear-facing position until your infant is 2 years old." The American Academy of Pediatrics (AAP) recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the height and weight limits specified by the car seat manufacturer for optimal safety.
B. "Fasten the harness over your infant's winter coat." Bulky clothing (such as winter coats) should not be worn under the harness because it can create excess space, reducing the effectiveness of the restraint and increasing injury risk. Instead, the infant should be dressed in thin layers, and a blanket can be placed over the secured harness if warmth is needed.
C. "Ensure the airbag is activated if the car seat is in the front passenger seat." Infants should never be placed in the front passenger seat if the car has an active airbag. Airbags can cause severe injury or death if deployed while a rear-facing car seat is in place. The safest position is always in the back seat.
D. "Pad the backrest of the car seat with a thick blanket before securing your infant." Additional padding should not be used, as it can interfere with the proper fit of the harness and compromise safety. Car seats are designed to provide adequate support and protection without extra cushioning.
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