A nurse is caring for the child the following day.

Exhibits

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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. Ask the child to hold their breath while the IV catheter is placed: This technique is not appropriate for a preschool-age child. Breath-holding may increase anxiety and is more applicable to older children or adults during procedures such as injections or venipuncture.

B. Place the IV catheter on the dominant arm: The non-dominant arm is usually preferred for IV insertion to reduce interference with the child's movement and play, and to prevent dislodgement of the catheter during activity.

C. Apply vapocoolant spray before the IV insertion: Vapocoolant sprays provide topical analgesia and can reduce the pain and anxiety associated with IV placement. This is especially helpful for young children like preschoolers and is recommended for pain management.

D. Explain the procedure to the child in detail: Preschoolers benefit from simple, age-appropriate explanations rather than detailed medical descriptions. Using clear, brief explanations or play-based preparation is more effective for their developmental level.

Rationale for Correct Answers:

• Preparing for a lumbar puncture: The child exhibits symptoms consistent with possible bacterial meningitis, including headache, lethargy, irritability, and nuchal rigidity. A lumbar puncture is necessary to obtain cerebrospinal fluid for diagnostic confirmation.
• Neurological findings: Signs like lethargy, nuchal rigidity, and severe headache strongly suggest central nervous system involvement. These findings indicate increased risk of meningitis, warranting immediate evaluation via lumbar puncture.

Rationale for Incorrect Choices:

• Administering potassium chloride: The child's potassium level is 3.8 mEq/L, which falls within the normal range. There is no indication of hypokalemia or need for potassium supplementation.
• Initiating airborne precautions: Bacterial meningitis requires droplet precautions, not airborne. Airborne precautions are reserved for illnesses like tuberculosis or measles.
• Administering acyclovir: There is no indication of viral infection such as herpes simplex or varicella. The presentation and history align more with bacterial meningitis than a viral cause.
• Increasing environmental stimuli: The child is irritable and lethargic, so increased stimuli would be contraindicated. A quiet, low-stimulation environment is more appropriate for neurologically compromised children.
• Pain level: Although pain is present (7/10 headache), the more critical finding prompting a lumbar puncture is the constellation of neurological symptoms rather than pain alone.
• WBC: An elevated WBC supports infection but is nonspecific. It should be interpreted alongside neurologic symptoms to justify a lumbar puncture.
• Lymph node findings: Slightly enlarged cervical nodes could be residual from a prior URI and are not the primary reason for a lumbar puncture in this context.
• Potassium level: The potassium is normal and unrelated to the need for a lumbar puncture or the child’s presenting concerns.