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 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 |
Respiratory rate 26/min
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","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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Your child will need to receive sedation to minimize pain during the test.": Sedation is not required for a sweat chloride test because it is noninvasive and painless. The procedure involves stimulating sweat production with pilocarpine and collecting the sweat for analysis.
B. "Two separate samples will be collected to ensure accuracy of the test results.": Collecting two sweat samples helps confirm the diagnosis of cystic fibrosis and minimizes the chance of error. Consistency across both samples increases the reliability of the test results.
C. "Your child should avoid eating and drinking 6 hours prior to the test.": Fasting is not necessary for a sweat chloride test. The child can eat and drink normally before the procedure, as diet and fluid intake do not affect the accuracy of the test.
D. "It will take approximately 3 hours to complete the test.": The sweat chloride test generally takes about 1 hour, including preparation and collection. It does not require prolonged testing time, making this statement inaccurate.
Correct Answer is D
Explanation
A. Mild hematuria: In glomerulonephritis, hematuria is typically significant, often producing cola- or tea-colored urine. Mild hematuria alone would not reflect the degree of renal involvement usually seen with this condition.
B. Absent urine protein: Proteinuria is a common finding in glomerulonephritis due to increased permeability of the glomerular membrane. Absence of protein in the urine would not be expected.
C. Decreased blood potassium: Potassium levels usually remain normal or may increase if renal function becomes impaired. Hypokalemia is not a common laboratory finding in glomerulonephritis.
D. Hyponatremia: Children with glomerulonephritis often experience fluid retention and dilutional hyponatremia. The kidneys’ impaired ability to filter and excrete fluid contributes to low serum sodium levels.
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