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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 system

Findings

Respiratory

Respiratory rate 26/min

Cardiovascular

Heart rate 112/min

Capillary refill 4 seconds

Gastrointestinal

Hyperactive bowel sounds

Integumentary

Diaper area reddened

Extremities cool

Reports no tears

Neurologic

Lethargic

A.

Respiratory rate 26/min

B.

Heart rate 112/min

C.

Capillary refill 4 seconds

D.

Hyperactive bowel sounds

E.

Diaper area reddened

F.

Extremities cool

G.

Reports no tears

H.

Lethargic

Answer and Explanation

The Correct Answer is ["C","F","G","H"]

Rationale:

• Respiratory rate 26/min: A respiratory rate in the mid-20s is within the normal range for toddlers (20–30/min). The child shows no increased work of breathing, so this does not require immediate intervention.

• Heart rate 112/min: This heart rate falls within the normal toddler range of 90–140 beats per minute. It does not indicate tachycardia or circulatory collapse at this time. Therefore, it is not a priority concern.

• Capillary refill 4 seconds: A refill time greater than 2 seconds indicates impaired circulation and reduced tissue perfusion. This is often seen in dehydration or hypovolemic shock, requiring immediate intervention. Prolonged refill signals worsening cardiovascular compromise.

• Hyperactive bowel sounds: Increased bowel sounds are expected in the setting of diarrhea and rapid peristalsis. While uncomfortable, this finding is not life-threatening and does not require urgent follow-up.

• Diaper area reddened: Redness in the diaper area is most likely due to frequent stools causing skin irritation. While it requires nursing care, it is a localized issue and not an urgent systemic concern.

• Extremities cool: Cool extremities suggest peripheral vasoconstriction as the body tries to preserve blood flow to vital organs. This points to inadequate perfusion from fluid loss. If not addressed quickly, it may progress to shock.

• Reports no tears: Crying without tears is a clear sign of moderate to severe dehydration in children. It indicates the body no longer has adequate fluid reserves to maintain normal secretions. This finding requires prompt replacement of fluids.

• Lethargic: Lethargy signals a change in neurological status, which is a late sign of significant dehydration. It reflects decreased cerebral perfusion from hypovolemia. This is a critical finding that warrants urgent follow-up.


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Related Questions

Correct Answer is D

Explanation

A. "Offer your child foods that are low in calories.": Children with cystic fibrosis require increased caloric intake due to higher metabolic demands and malabsorption issues. A low-calorie diet would not meet their energy needs and could lead to poor growth and nutritional deficits.

B. "Offer your child foods that are low in protein.": Protein is essential for growth, tissue repair, and immune function, especially in children with cystic fibrosis who experience chronic illness. Restricting protein would worsen nutritional deficiencies and impair development.

C. "Offer your child foods that are high in vitamin C.": While vitamin C is beneficial for immune support, the primary concern in cystic fibrosis is fat and fat-soluble vitamin malabsorption (A, D, E, and K). Simply increasing vitamin C intake does not adequately address nutritional needs.

D. "Offer your child foods that are high in fat.": High-fat foods are encouraged for children with cystic fibrosis because they provide dense calories needed to meet high energy requirements. With pancreatic enzyme replacement, fat absorption is improved, making this the most appropriate dietary recommendation.

Correct Answer is B

Explanation

A. "Use lotion on the skin under the harness.": Lotions and powders should be avoided because they can cause skin irritation or breakdown when trapped under the straps. Instead, the skin should be kept clean and dry to prevent complications.

B. "Place the diaper under the straps.": Positioning the diaper under the harness straps helps maintain cleanliness of the harness and prevents soiling. This is an important part of daily care to protect both the infant’s skin and the harness.

C. "Avoid massaging the skin under the straps.": Gentle massage of the skin under the straps is encouraged to promote circulation and prevent skin breakdown. Avoiding massage could increase the risk of pressure injuries in these areas.

D. "Adjust the harness straps weekly.": Parents should not adjust the harness straps at home. Adjustments must be made by the healthcare provider to ensure correct positioning of the hips and to avoid complications related to improper use.

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