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A nurse is caring for an adolescent.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition most likely experiencing:

Pelvic Inflammatory Disease (PID)

Actions the nurse should take:

Place the adolescent on bedrest in semi-Fowler’s position
Administer acetaminophen 650 mg PO every 6 Hr PRN pain

Parameters to monitor:

Temperature greater than 38.3°C (100.9°F)
Rebound tenderness

Rationale:

Pelvic Inflammatory Disease (PID). The client’s history of multiple sexual partners, mucopurulent cervical discharge, pelvic pain, and fever strongly suggests PID, a bacterial infection often caused by sexually transmitted infections (STIs) such as chlamydia or gonorrhea.

Urinary tract infection. UTIs typically present with dysuria, urgency, frequency, and suprapubic pain, which are not noted here.

Ectopic pregnancy. The client’s last menstrual period was 7 days ago, making pregnancy unlikely. PID symptoms differ from ectopic pregnancy, which presents with unilateral lower abdominal pain and possibly vaginal bleeding.

Acute appendicitis. Appendicitis typically causes right lower quadrant pain, nausea, vomiting, and rebound tenderness, which are not the primary symptoms here.

Place the adolescent on bedrest in semi-Fowler’s position – This promotes drainage of infected fluids and reduces the risk of abscess formation.

Administer acetaminophen 650 mg PO every 6 Hr PRN pain – This helps manage the pain associated with PID.

Temperature greater than 38.3°C (100.9°F) – A rising temperature may indicate worsening infection or sepsis.

Rebound tenderness – Can indicate peritoneal irritation, which may suggest complications such as peritonitis or an abscess.

Instruct the adolescent about the use of sitz baths. Sitz baths are used for perineal discomfort but are not a standard intervention for PID.

Administer an enema. An enema is unnecessary and could worsen the infection if peritonitis is present.

Vaginal bleeding. Vaginal bleeding is not a common symptom of PID.

Irritation of the phrenic nerve. Phrenic nerve irritation is associated with diaphragmatic irritation, such as in gallbladder disease or ruptured ectopic pregnancy.

Presence of a Cullen sign. Cullen’s sign (bluish discoloration around the umbilicus) is a sign of intra-abdominal hemorrhage, often seen in ruptured ectopic pregnancy or pancreatitis, not PID.

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Free Nursing Study Resources

Correct Answer is ["A","D","E","G"]

Explanation

A. Apply pressure to the puncture site following the procedure. Applying pressure helps prevent cerebrospinal fluid (CSF) leakage and reduces the risk of complications.

B. Limit the child's fluid intake following the procedure. Fluids should be encouraged to help replenish lost CSF and reduce the risk of post-lumbar puncture headache.

C. Position the child in a prone position during the procedure. The correct positioning for a lumbar puncture is the side-lying fetal position or sitting with the back curved forward to widen the space between the vertebrae.

D. Ensure the guardian has signed the consent form prior to the procedure. A lumbar puncture is an invasive procedure, so informed consent is required before proceeding.

E. Ensure the child voids prior to the procedure. Having the child empty their bladder before the procedure helps prevent discomfort and reduces the risk of bladder distention during positioning.

F. Insert an indwelling urinary catheter during the procedure. A urinary catheter is not necessary for a lumbar puncture unless there is another medical indication.

G. Monitor for paresthesia and tingling in extremities following the procedure. Paresthesia or tingling could indicate nerve irritation or injury, which requires prompt assessment and intervention.

A. Elevated temperature B. Neurological deficit C. Inspiratory wheezing D. Rapid respirations

Correct Answer is B

Explanation

A. Elevated temperature. An elevated temperature is a common symptom of infection, including bacterial pneumonia, but it is not a direct risk factor for aspiration. The concern for aspiration is more related to a child's ability to protect their airway.

B. Neurological deficit. A neurological deficit, such as a decreased level of consciousness or impaired swallowing reflexes, increases the risk of aspiration. A child with neurological impairment may have difficulty swallowing or protecting their airway, making them more prone to inhaling food, fluids, or other substances into the lungs, leading to aspiration pneumonia.

C. Inspiratory wheezing. Inspiratory wheezing is more likely to be associated with conditions like asthma or airway obstruction, not specifically with aspiration. It does not directly indicate a risk for aspiration.

D. Rapid respirations. Rapid respirations can be a sign of respiratory distress, common in pneumonia, but they do not directly indicate a risk for aspiration. The risk for aspiration is more closely linked to issues with swallowing and airway protection, not just the rate of respiration.

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A nurse is caring for an adolescent. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A pediatrician has evaluated the child and has written new prescriptions. The nurse is preparing to assist with a lumbar puncture. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","D","E","G"]

Explanation

A nurse is assessing a child who has bacterial pneumonia. Which of the following findings should the nurse identify as a potential risk for aspiration?

Correct Answer is B

Explanation

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A nurse is caring for an adolescent.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.