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A nurse is caring for a toddler admitted to the hospital.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body Systems

Findings

Respiratory

Respiratory rate 26/min

Cardiovascular

Heart rate 112/min

Capillary refill 4 seconds

Gastrointestinal

Hyperactive bowel sounds

Integumentary

Diaper area reddened with erythema noted

Extremities cool

Reports no tears

Neurologic

Lethargic

Capillary refill 4 seconds

Hyperactive bowel sounds

Diaper area reddened with erythema noted

Extremities cool

Reports no tears

Lethargic

Respiratory rate 26/min

Heart rate 112/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.

Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.

Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.

Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.

Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Scheduling meals at 6-hour intervals is inadequate as clients with major burns require frequent, high-calorie intake.

B. A calorie intake of 1,500 per day is insufficient for burn clients, who require significantly higher caloric intake to support healing.

C. Keeping a calorie count helps ensure the client is meeting their increased nutritional needs for wound healing and recovery.

D. A high-protein, high-carbohydrate diet is necessary, not a low-protein diet, to support tissue repair and metabolic demands.

A. Tell the client, "You seem to be very upset." B. Initiate seclusion protocol. C. Engage the panic alarm. D. Use a face shield with a mask when providing care to the client.

Correct Answer is A

Explanation

A. Verbal de-escalation by acknowledging the client’s emotions (“You seem to be very upset”) helps to diffuse tension and can prevent further agitation.

B. Initiating seclusion should be a last resort after other de-escalation techniques fail.

C. Engaging the panic alarm is necessary only if the client becomes physically violent.

D. Using a face shield is not warranted unless there is a risk of bodily fluid exposure.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?

Correct Answer is A

Explanation

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