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.
The Correct Answer is []
Rationale for Correct Choices
• Pelvic inflammatory disease: The client’s fever, pelvic pain, mucopurulent cervical discharge, elevated WBC and CRP, and positive chlamydia test point to pelvic inflammatory disease, a complication of untreated sexually transmitted infection.
• Instruct the adolescent about the use of sitz baths: Sitz baths provide localized warmth and comfort, reducing pelvic and abdominal pain while promoting circulation and relaxation in the pelvic region.
• Administer acetaminophen 650 mg PO every 6 hr PRN pain: Acetaminophen helps relieve pelvic cramping, fever, and discomfort, improving the client’s ability to tolerate care and promoting rest.
• Vaginal bleeding: PID can damage reproductive tissue, increasing risk of abnormal vaginal bleeding, so monitoring helps detect complications such as worsening infection or endometrial involvement.
• Temperature greater than 38.3° C (100.9° F): Persistent fever indicates ongoing infection or ineffective antibiotic therapy, making temperature an essential marker for evaluating treatment response.
Rationale for Incorrect Choices
• Acute appendicitis: This condition presents with right lower quadrant pain, rebound tenderness, and elevated inflammatory markers, but mucopurulent cervical discharge and positive chlamydia culture make PID more likely.
• Urinary tract infection: A UTI typically causes dysuria, frequency, and pyuria in urinalysis, but this client’s urine shows no WBCs or nitrites, making this diagnosis unlikely.
• Ectopic pregnancy: The negative hCG rules out pregnancy-related causes such as ectopic pregnancy, despite the abdominal pain.
• Maintain an NPO status: This is appropriate for appendicitis or surgical conditions, not PID, which is treated with antibiotics and comfort measures.
• Administer an enema: This is unrelated to PID management and could worsen discomfort without addressing the infection.
• Place the adolescent on bedrest in semi-Fowler’s position: This is more appropriate for appendicitis or abdominal surgery; PID management focuses on antibiotics, comfort, and symptom control instead.
• Rebound tenderness: While possible in appendicitis, this is not a priority assessment in PID, where infection signs and pelvic pain predominate.
• Presence of a Cullen sign: Cullen’s sign indicates intra-abdominal bleeding, often from ruptured ectopic pregnancy or pancreatitis, not PID.
• Irritation of the phrenic nerve: Phrenic nerve irritation, often causing shoulder tip pain, is associated with a ruptured spleen or ectopic pregnancy, and is not typical of PID.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage use of a digital gaming device: Bright screens and sensory stimulation can worsen discomfort in a child with bacterial meningitis, as these clients are often sensitive to light and noise. Rest in a quiet, dim environment is more appropriate.
B. Avoid raising the head of the child's bed: Elevating the head of the bed to 30 degrees helps reduce intracranial pressure and promotes venous drainage. Avoiding elevation could worsen symptoms and increase complications.
C. Place the child on seizure precautions: Children with bacterial meningitis are at increased risk for seizures due to inflammation and irritation of the meninges. Seizure precautions, such as padded side rails and having emergency equipment available, are essential.
D. Maintain contact precautions for 24 hr after the start of antibiotics: Bacterial meningitis requires droplet precautions, not contact precautions, for at least 24 hours after antibiotics are initiated. Using the wrong type of isolation would not prevent transmission effectively.
Correct Answer is ["C","F","G","H"]
Explanation
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.
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