A nurse is caring for a toddler admitted to the hospital.
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
|
Body system |
Findings |
|
Respiratory |
Respiratory rate 264min |
|
Cardiovascular |
Heart rate 112/min Capillary refill 4 seconds |
|
Gastrointestinal |
Hyperactive bowel sounds |
|
Integumentary |
Diaper area reddened Extremities cool Reports no tears |
|
Neurologic |
Lethargic |
Respiratory rate 264min
Heart rate 112/min
Capillary refill 4 seconds
Hyperactive bowel sounds
Diaper area reddened
Extremities cool Reports no tears
Lethargic
The Correct Answer is ["C","F","G"]
Capillary refill 4 seconds (Cardiovascular) – Indicates poor perfusion and worsening dehydration.
Extremities cool (Integumentary) – Suggests impaired circulation, potential hypovolemia.
Reports no tears (Integumentary) – Sign of severe dehydration.
Lethargic (Neurologic) – Worsening mental status, could indicate hypovolemia or electrolyte imbalance.
Heart rate 112/min – Mildly elevated but not yet critical.
Respiratory rate 26/min – Within an acceptable range for a toddler.
Hyperactive bowel sounds – Expected with diarrhea.
Diaper area reddened – Needs care but not urgent
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I wish I knew what I did to cause my child to be sick." This statement reflects self-blame and guilt, which are signs of poor coping.
B. "I saw on the internet that there's a new treatment option." This demonstrates hope and proactive coping, as the guardian is seeking information and exploring options.
C. "I don't want my family to know about my child's diagnosis." Avoiding support from family may indicate denial or isolation, which are maladaptive coping strategies.
D. "I am not sure how to care for my dying child." Expressing uncertainty about caregiving suggests distress and a need for additional support and education, rather than positive adjustment.
Correct Answer is D
Explanation
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
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