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 A
Explanation
A. Pale, oily stools: Celiac disease causes malabsorption due to an immune response to gluten, leading to steatorrhea. The stools are typically pale, foul-smelling, and oily because of impaired fat absorption.
B. Redcurrant, jelly-like stools: This type of stool is characteristic of intussusception, a condition where part of the intestine telescopes into itself, causing bleeding and mucus, not celiac disease.
C. Increased hemoglobin level: Children with celiac disease often experience iron deficiency anemia due to malabsorption, which lowers hemoglobin levels. An increase in hemoglobin would not be expected.
D. Hematemesis: Vomiting blood is not a typical finding in celiac disease. It is more commonly associated with upper gastrointestinal bleeding from ulcers or esophageal varices.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for correct choices:
• Seizures: Clients with meningitis are at risk for seizures due to meningeal irritation, high fever, and increased intracranial pressure. Neurological complications arise as the infection spreads within the central nervous system, disrupting electrical activity in the brain.
• Level of consciousness: The adolescent is lethargic, drowsy, and irritable when aroused, which reflects altered neurological status. This finding indicates cerebral involvement, which increases the likelihood of seizure activity as the illness progresses.
Rationale for incorrect choices:
• Lyme disease: This condition is caused by tick bites and typically presents with erythema migrans rash, arthralgia, and fatigue, not acute fever, photophobia, or purpuric rash as seen here.
• Pneumonia: Respiratory involvement would present with abnormal breath sounds, cough, or hypoxemia, but this client has clear lung sounds and normal oxygen saturation, making pneumonia unlikely.
• Mononucleosis: This condition usually causes fever, pharyngitis, and lymphadenopathy, but the client’s cervical nodes are normal and their presentation aligns more with meningitis.
• Constipation: Gastrointestinal complications such as constipation are not relevant here since bowel sounds are active, the abdomen is soft, and there are no reports of decreased stooling.
• Abdominal findings: The abdomen is soft, flat, and with normal bowel sounds, which provides no evidence of an abdominal complication linked to meningitis risk.
• Rash: While the purpuric rash supports the diagnosis of meningococcal meningitis, it is not the primary indicator of seizure risk. Neurological status is a stronger predictor of seizure development.
• Cervical lymph nodes: These are normal without edema or tenderness, ruling out lymphatic involvement as a significant concern in this scenario.
• Breath sounds: Breath sounds are clear and equal bilaterally, which excludes a respiratory complication such as pneumonia as the risk factor linked to seizures.
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