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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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Violating others' rights is more characteristic of antisocial personality disorder.

B. Self-centered behavior is a hallmark of histrionic personality disorder. Clients often seek attention, exhibit excessive emotionality, and display dramatic, exaggerated behaviors.

C. Callousness is also seen in antisocial personality disorder rather than histrionic.

D. Suspiciousness is typical of paranoid personality disorder, not histrionic.

A. Limit the client's opportunities to socialize with others. B. Speak in a neutral tone when addressing the client. C. Rotate staff members caring for the client. D. Mix the medication with the client's food items.

Correct Answer is B

Explanation

A. Socialization can promote trust and reduce isolation, so limiting socialization is not beneficial.

B. Speaking in a neutral tone helps build trust and reduces perceived threats in clients with paranoid personality disorder, who may be suspicious of others' intentions.

C. Consistency in caregivers fosters trust, so rotating staff frequently may exacerbate the client's paranoia.

D. Mixing medication with food without the client's knowledge breaches trust and ethical guidelines.

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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 assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?

Correct Answer is B

Explanation

A nurse is creating a plan of care for a client who has paranoid personality disorder and refuses to take their medication. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who is on bed rest. The nurse should recognize that which of the following findings is a complication of immobility?

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A nurse is caring for a client who has an implanted venous access port. Which of the following should the nurse use to access the port?

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