A nurse is caring for a pediatric client receiving radiation therapy to the abdominal area. Which of the following statements by the nurse promotes proper skin integrity for the client?

Rationale for Correct Answers:

• Preparing for a lumbar puncture: The child exhibits symptoms consistent with possible bacterial meningitis, including headache, lethargy, irritability, and nuchal rigidity. A lumbar puncture is necessary to obtain cerebrospinal fluid for diagnostic confirmation.
• Neurological findings: Signs like lethargy, nuchal rigidity, and severe headache strongly suggest central nervous system involvement. These findings indicate increased risk of meningitis, warranting immediate evaluation via lumbar puncture.

Rationale for Incorrect Choices:

• Administering potassium chloride: The child's potassium level is 3.8 mEq/L, which falls within the normal range. There is no indication of hypokalemia or need for potassium supplementation.
• Initiating airborne precautions: Bacterial meningitis requires droplet precautions, not airborne. Airborne precautions are reserved for illnesses like tuberculosis or measles.
• Administering acyclovir: There is no indication of viral infection such as herpes simplex or varicella. The presentation and history align more with bacterial meningitis than a viral cause.
• Increasing environmental stimuli: The child is irritable and lethargic, so increased stimuli would be contraindicated. A quiet, low-stimulation environment is more appropriate for neurologically compromised children.
• Pain level: Although pain is present (7/10 headache), the more critical finding prompting a lumbar puncture is the constellation of neurological symptoms rather than pain alone.
• WBC: An elevated WBC supports infection but is nonspecific. It should be interpreted alongside neurologic symptoms to justify a lumbar puncture.
• Lymph node findings: Slightly enlarged cervical nodes could be residual from a prior URI and are not the primary reason for a lumbar puncture in this context.
• Potassium level: The potassium is normal and unrelated to the need for a lumbar puncture or the child’s presenting concerns.

A. Bradycardia: Bradycardia is not typical in infants with congestive heart failure (CHF); instead, tachycardia is common as the heart tries to compensate for poor cardiac output.

B. Increased blood pressure: While some compensatory mechanisms can transiently affect blood pressure, infants with CHF often have decreased cardiac output, which can lead to normal to decreased blood pressure rather than an increase.

C. Increased urine output: Urine output often decreases in CHF because of reduced renal perfusion and activation of compensatory mechanisms like the renin-angiotensin system, leading to fluid retention.

D. Tachypnea: Tachypnea is a common finding in infants with CHF as the body attempts to compensate for poor oxygenation and fluid buildup in the lungs, causing rapid breathing and respiratory distress.