A nurse is caring for an adolescent.

Exhibits
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 []

Pelvic Inflammatory Disease (PID): The client’s mucopurulent cervical discharge, pelvic pain, recent multiple sexual partners, fever, and urinary discomfort point strongly toward PID, a common infection of the upper genital tract in sexually active adolescents.
Administer acetaminophen 650 mg PO every 6 hr PRN pain: Acetaminophen is appropriate for managing PID-associated fever and cramping pain without interfering with diagnostic assessments.
Place the adolescent on bedrest in semi-Fowler's position: Semi-Fowler's positioning facilitates pelvic drainage, reduces the risk of abscess formation, and supports comfort.
Temperature greater than 38.3°C (100.9°F): Ongoing fever indicates systemic infection or lack of response to treatment, making it a key marker for disease progression or resolution.
Vaginal bleeding: Monitoring for abnormal bleeding is important, as PID can involve endometrial inflammation or complications like ectopic pregnancy or miscarriage if not promptly managed.

Rationale for Incorrect Choices:

Urinary tract infection: UTIs typically cause dysuria, frequency, and suprapubic pain, but PID presents with more systemic symptoms and pelvic tenderness, along with sexual history risk factors.
Ectopic pregnancy: Though a possibility, the client recently had her period 7 days ago, making active ectopic pregnancy less likely; there is also no mention of missed periods or positive pregnancy test.
Acute appendicitis: This usually involves right lower quadrant pain and rebound tenderness; cervical discharge and bilateral pelvic pain make PID more likely.
Instruct the adolescent about the use of sitz baths: Sitz baths help with localized perineal discomfort but are not primary management for PID.
Administer an enema: This is unrelated to PID and could worsen abdominal discomfort or cause unnecessary complications.
Maintain an NPO status: NPO is reserved for surgical cases or procedures requiring sedation; PID is typically managed with medications and does not require dietary restrictions.
Rebound tenderness: While it can indicate peritonitis as a result of peritoneal irritation, it's more typical of appendicitis than PID.
Presence of a Cullen’s sign: Cullen’s sign (periumbilical bruising) is associated with intra-abdominal bleeding such as pancreatitis or ruptured ectopic pregnancy, not PID.
Irritation of the phrenic nerve: This is associated with upper abdominal pathology like gallbladder disease, not with PID.

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Correct Answer is A

Explanation

A. Mild hematuria: Glomerulonephritis commonly causes inflammation of the glomeruli, leading to leakage of red blood cells into the urine. This results in mild hematuria, which is a typical laboratory finding in this condition. The presence of blood in the urine reflects glomerular damage.

B. Absent urine protein: Proteinuria is usually present in glomerulonephritis due to increased glomerular permeability. The absence of urine protein would be unusual and inconsistent with this diagnosis, as protein leakage often occurs alongside hematuria.

C. Hyponatremia: Although hyponatremia can sometimes occur in glomerulonephritis due to fluid retention and dilution, it is not a primary or consistent laboratory finding. Sodium levels may remain normal or fluctuate depending on the severity of the condition and fluid status.

D. Decreased blood potassium: Potassium levels are typically not decreased in glomerulonephritis. In fact, some cases may show normal or elevated potassium levels due to impaired kidney function and reduced excretion, making decreased potassium an unlikely finding.

A. Vomiting B. Pinpoint pupils C. Sunken anterior fontanel D. Hypertonia

Correct Answer is A

Explanation

A. Vomiting: Vomiting is a common sign of increased intracranial pressure, which can occur with a subdural hematoma in infants. It often accompanies other neurological symptoms such as irritability or lethargy.

B. Pinpoint pupils: Pinpoint pupils are more commonly associated with opioid overdose or pontine brain injury, not typically with subdural hematoma. Pupillary changes in subdural hematoma more often involve unequal or dilated pupils.

C. Sunken anterior fontanel: A sunken fontanel indicates dehydration, not increased intracranial pressure. In subdural hematoma, the fontanel may be bulging or tense due to increased pressure.

D. Hypertonia: Muscle tone changes can vary, but hypotonia (decreased tone) is more commonly seen in infants with brain injury. Hypertonia may occur later but is not a classic early sign of subdural hematoma.

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