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A nurse is caring for the child the following day.

Click to highlight the findings that indicate the child is progressing as expected. To deselect a finding, click on the finding again.

Nurses' Notes

Day 2, 0730:

Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present. Mucous membranes pink and moist. Cervical lymph slightly enlarged. Respirations are regular. No accessory muscle use noted. Breath sounds clear anterior posterior bilaterally. Heart rhythm regular without murmurs. Radial pulse 2+ bilateral. Capillary refill less than 2 seconds. Abdomen flat and non- distended. Bowel sounds active in all 4 quadrants. Extremities are warm and dry to touch. Good skin turgor.

Flow Sheet

Temperature 38.9° C (102° F)

Heart rate 104/min

Respiratory rate 24/min

Blood pressure 104/80 mm Hg

SpO2 98% on room air

A.

Mucous membranes pink and moist

B.

Breath sounds clear anterior posterior bilaterally

C.

Radial pulse 2+ bilateral

D.

Capillary refill less than 2 seconds

E.

Bowel sounds active in all 4 quadrants

F.

Extremities are warm and dry to touch

G.

Good skin turgor

H.

Heart rate 104/min

I.

Respiratory rate 24/min

J.

SpO2 98% on room air

K.

Temperature 38.9° C (102° F)

L.

Drowsy and lethargic

M.

Nuchal rigidity present

N.

Cervical lymph slightly enlarged

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F","G","H","I","J"]

  • Heart rate 104/min – The heart rate has decreased from 114/min on Day 1, indicating improvement.
  • Respiratory rate 24/min – The respiratory rate has decreased from 26/min, showing stabilization.
  • SpO₂ 98% on room air – Oxygen saturation remains stable and adequate.
  • Mucous membranes pink and moist – Indicates improved hydration.
  • Radial pulse 2+ bilateral – Stronger pulse compared to the previous day’s 1+, suggesting better circulation.
  • Capillary refill less than 2 seconds – Improved from the previous day’s delayed refill (4 seconds), showing better perfusion.
  • Extremities warm and dry to touch – Indicates adequate circulation and hydration.
  • Good skin turgor – Suggests the child is well-hydrated.
  • Bowel sounds active in all 4 quadrants – Indicates normal gastrointestinal function.
  • Breath sounds clear anterior and posterior bilaterally – No respiratory distress or abnormal findings.

Findings that do not indicate improvement:

  • Temperature 38.9°C (102°F) – Slightly higher than the previous day (38.7°C), suggesting persistent fever.
  • Drowsy and lethargic – The child is still lethargic, which may indicate ongoing illness.
  • Nuchal rigidity present – No improvement in meningitis-related symptoms.
  • Cervical lymph slightly enlarged – Indicates ongoing immune response.


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Related Questions

Correct Answer is B

Explanation

A. "It is okay to blame others for your feelings." Blaming others is a negative coping mechanism that does not help the child manage emotions in a healthy way.
B. "When you feel angry and overwhelmed, take some deep breaths." Deep breathing is a positive coping strategy that helps reduce stress and manage emotions effectively.
C. "Take a break from group activities when you are stressed." Social support is an important stress reliever, and withdrawing from activities may lead to isolation and worsen stress.
D. "Keep your strong feelings to yourself." Bottling up emotions can lead to increased stress and anxiety. Children should be encouraged to express their feelings in a healthy way.

Correct Answer is B

Explanation

A. "Introduce solid foods when the infant reaches 3 months of age." Solid foods should be introduced around 4 to 6 months of age, when the infant shows signs of readiness (e.g., sitting with support, loss of tongue-thrust reflex).
B. "Offer 1 tablespoon as a serving size for the infant's solid food." A general guideline is 1 tablespoon of food per year of age per serving, so for an infant just starting solids, 1 tablespoon is appropriate per meal.
C. "Add 1 teaspoon of honey to the infant's bottle of formula if constipation occurs." Honey should not be given to infants under 1 year old due to the risk of botulism.
D. "Introduce the infant to a new solid food every other day." New foods should be introduced one at a time, every 3 to 5 days, to monitor for potential allergic reactions.

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