A nurse is caring for the child the following day.
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
Mucous membranes pink and moist
Respirations are regular
Radial pulse 2+ bilateral. Capillary refill less than 2 seconds
Drowsy and lethargic, but responsive to verbal stimuli. Nuchal rigidity present
Cervical lymph slightly enlarged
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
The Correct Answer is ["A","B","C","G","H","I","J"]
Rationale for Correct Answers:
- Mucous membranes pink and moist: Reflects adequate hydration and improved fluid status compared to previous "dry and sticky" description.
- Respirations are regular/ RR 24/min: Indicates stable respiratory function with no signs of distress or respiratory compromise as compared to the previous irregular respirations
- HR 104/min / BP 104/80 mm Hg: Demonstrates cardiovascular stability within age-appropriate ranges and an improvement from the initial readings
- Radial pulse 2+ bilateral / Cap refill < 2 seconds: Suggests good perfusion and improved circulatory status compared to previous delayed cap refill and weak pulses.
- SpO₂ 98% on room air: Demonstrates sufficient oxygenation without need for respiratory support and an improvement from 97%.
Rationale for Incorrect Choices:
- Drowsy and lethargic, but responsive to verbal stimuli: Neurologic status has not improved from the previous day; continued lethargy and altered mental status require ongoing evaluation.
- Nuchal rigidity present: This is a classic sign of meningeal irritation and ongoing central nervous system involvement; it has not resolved and remains concerning.
- Temperature 38.9°C (102°F): The elevated temperature indicates persistent fever, suggesting that the infection or inflammation is still active.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Indicate on a stuffed animal where the procedure will be performed: Demonstrating on a stuffed animal is more appropriate for younger children such as toddlers or preschoolers. School-age children benefit more from visual aids that relate to their own bodies.
B. Provide teaching immediately before the procedure: Teaching right before surgery can increase anxiety and does not allow the child adequate time to process information or ask questions.
C. Use simple diagrams to explain the procedure: Visual aids like simple diagrams help school-age children understand what will happen in a way that is appropriate for their cognitive level, reducing fear and promoting cooperation.
D. Discuss the benefits of the procedure: While discussing benefits is important, the primary focus before surgery should be clear, age-appropriate explanations of the procedure itself to prepare the child effectively.
Correct Answer is C
Explanation
A. "Your child will need to receive sedation to minimize pain during the test.": Sedation is not necessary for a sweat chloride test. The test is noninvasive and painless, involving stimulation of sweat glands using a mild electric current.
B. "It will take approximately 3 hours to complete the test.": The entire sweat chloride test usually takes about 1 hour or less, including preparation and collection time. It is a quick procedure, not lasting multiple hours.
C. "Two separate samples will be collected to ensure accuracy of the test results.": Collecting two samples helps confirm the diagnosis, as elevated sweat chloride levels in both are indicative of cystic fibrosis. Repeat testing improves diagnostic reliability.
D. "Your child should avoid eating and drinking 6 hours prior to the test.": Fasting is not required for a sweat chloride test. The child can eat and drink normally before the procedure, as it does not affect the results.
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