A nurse is caring for a toddler.
Which of the following findings require immediate follow-up by the nurse?
Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Nurses' Notes
0920:
Toddler is irritable, sitting on guardian's lap. Clear drainage draining from nose. Oral mucosa dry. Cervical lymph nodes nonpalpable. Lung sounds clear in all lung fields. Nonproductive, occasional cough present. Apical heart rate regular, no murmur. Capillary refill 3 seconds. Abdomen nontender, bowel sounds hyperactive.
Previous weight (4 weeks ago) 12 kg (26.5 lb)
Current weight 11.4 kg (25 lb)
Vital Signs
0910:
- Temperature 39.6° C (103.2° F)
- Blood pressure 88/42 mm Hg
- Heart rate 150/min
- Respiratory rate 28/min
- Oxygen saturation 96% on room air
Toddler is irritable, sitting on guardian's lap
Oral mucosa dry
Lung sounds clear in all lung fields
Apical heart rate regular, no murmur
Capillary refill 3 seconds
Current weight 11.4 kg (25 lb)
Temperature 39.6° C (103.2° F)
Blood pressure 88/42 mm Hg
Heart rate 150/min
Respiratory rate 28/min
Oxygen saturation 96% on room air
The Correct Answer is ["A","B","E","F","G","H","I"]
Rationale for Correct Choices
- Toddler is irritable: Irritability in a young child is a red flag for worsening systemic illness, dehydration, or early hypoxia, and requires close observation and intervention.
- Oral mucosa dry: This is a classic clinical sign of dehydration. It indicates that the toddler's body is losing more fluids than it's taking in, leading to a fluid volume deficit.
- Temperature 39.6° C (103.2° F): A persistent high fever in a toddler increases the risk of dehydration and febrile seizures. It requires prompt intervention with antipyretics and fluids to prevent further complications.
- Blood pressure 88/42 mm Hg: This is hypotension for a 2-year-old, suggesting compromised perfusion. Immediate action is needed as this can indicate progressing dehydration or early septic shock.
- Heart rate 150/min: Tachycardia in toddlers may indicate dehydration, fever, or compensatory response to low blood pressure. If unaddressed, it can progress to cardiovascular instability.
- Capillary refill 3 seconds: Prolonged refill indicates poor peripheral perfusion, which often accompanies dehydration or hypovolemia. This is a red flag for impaired circulation and worsening shock.
- Weight loss from 12 kg to 11.3–11.4 kg: A loss of nearly 6% body weight in a short period is clinically significant dehydration in a toddler. This requires prompt fluid replacement to avoid further decline.
Rationale for Incorrect Choices
- Respiratory rate 28/min: This rate is within the normal range for a 2-year-old (20–30 breaths/min). Without distress, retractions, or desaturation, it does not require immediate follow-up.
- Oxygen saturation 96% on room air: This is an acceptable oxygen level in a toddler. There are no signs of hypoxemia or respiratory compromise requiring intervention.
- Apical heart rate regular, no murmur: A regular rhythm without abnormal sounds indicates stable cardiac function. No immediate follow-up is required here.
- Lung sounds clear in all fields: The absence of wheezing, crackles, or diminished sounds rules out acute respiratory distress, so no intervention is immediately required.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Record intake and output: Monitoring intake and output is important for overall care, especially if the child is receiving IV therapy. However, this is not the priority action when initially admitting a child with suspected osteomyelitis.
B. Request a referral for physical therapy: Physical therapy may be beneficial later in the treatment course to restore mobility and function. It is not a priority during the acute phase of infection when diagnostic and medical interventions take precedence.
C. Administer IV antibiotics: IV antibiotics are the mainstay of treatment for osteomyelitis, but they should be started after cultures are obtained. Giving antibiotics first could alter culture results and compromise accurate pathogen identification.
D. Obtain a blood culture: Blood cultures should be obtained before initiating antibiotic therapy to identify the causative organism. This ensures the child receives the most effective, targeted treatment, making it the priority initial action.
Correct Answer is D
Explanation
A. Reschedule the procedure until the client's guardian provides written consent: In most states, adolescents have the legal right to consent to reproductive health services, including contraception. Guardian consent is not required for IUD insertion.
B. Call the adolescent's guardian to obtain verbal consent prior to the procedure: Involving a guardian without the adolescent’s permission breaches confidentiality. Reproductive health decisions are protected for adolescents, and verbal consent from a guardian is unnecessary.
C. Encourage the adolescent to wait to ask questions about the device until after its insertion: It is essential for the adolescent to receive complete education and have all questions answered before the procedure. Informed consent cannot be obtained after the procedure has already been done.
D. Witness the adolescent's signature on the consent form: Adolescents can legally provide consent for contraception. The nurse’s role is to witness the signature, ensuring the adolescent understands the procedure and that the consent is voluntary.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.