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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 D

Explanation

A. "Provide chicken or beef broth until the diarrhea subsides." Broth can be high in sodium, which is not ideal for rehydrating a child with diarrhea. Clear fluids and oral rehydration solutions are better choices.

B. "Encourage intake of carbonated beverages diluted with water." Carbonated beverages can irritate the stomach and exacerbate diarrhea. Instead, clear fluids or oral rehydration solutions are recommended.

C. "Provide the child with a bananas, rice, applesauce, and toast (BRAT) diet." The BRAT diet is outdated and not recommended anymore because it lacks essential nutrients. Instead, the child should be provided with a balanced diet, including foods like rice, potatoes, and lean meats, along with fluids for rehydration.

D. "Administer oral hydration solution after each diarrheal stool." Oral rehydration solutions (ORS) help replace lost fluids and electrolytes. Administering ORS after each stool helps prevent dehydration, which is a common complication of diarrhea.

Correct Answer is C

Explanation

A. Urine output 25 mL/hr – This is an adequate urine output for a school-age child and does not require withholding digoxin.
B. Oxygen saturation 88% – While low, this does not directly indicate digoxin toxicity or require withholding the medication. The underlying cause should be evaluated.
C. Heart rate 64/min – Digoxin can cause bradycardia, and a heart rate of 64/min is too low for a school-age child. Generally, digoxin should be withheld if the heart rate is below 70 bpm in children or below 90 bpm in infants.
D. Respiratory rate 18/min – This is within the normal range for a school-age child and does not warrant withholding digoxin.

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