A nurse on a pediatric unit is receiving a report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first?

A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%

A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F)

A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002

A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale

Answer and Explanation

The Correct Answer is C

A. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%. While status asthmaticus is a serious condition, a pulse oximetry reading of 95% indicates adequate oxygenation, so this child is not in immediate distress.

B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F). While the fever requires monitoring and treatment, roseola is typically a self-limiting illness, and this temperature, while high, is not immediately life-threatening.

C. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002. A urine specific gravity of 1.002 indicates very dilute urine, which is concerning for diabetes insipidus and potential dehydration. This condition requires immediate attention to prevent severe dehydration and electrolyte imbalance.

D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale. While managing pain in sickle cell anemia is important, the child’s condition is stable, and pain relief can be addressed after assessing the more urgent case of potential dehydration in the child with diabetes insipidus.

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Correct Answer is A

Explanation

A. Ask the child what he knows about the procedure. Understanding the child’s knowledge and feelings about the procedure helps tailor the explanation to address any misconceptions and reduce anxiety. This is the first step in providing appropriate and effective education.

B. Allow the child to see and touch IV tubing and supplies. Familiarizing the child with the equipment can reduce fear, but it is better to first assess what the child knows and address any concerns or fears before showing the supplies.

C. Describe the procedure using visual aids. Using visual aids to explain the procedure is helpful, but it should follow assessing the child’s current understanding to ensure the explanation is appropriate and comprehensive.

D. Explain to the child's parents what role they will have during the procedure. Involving the parents and explaining their role is important, but the child’s understanding and comfort should be addressed first to ensure they are calm and prepared for the procedure.

A. Brisk pupillary reaction to light B. Irritability C. Tachycardia D. Increased sensory response to painful stimuli

Correct Answer is B

Explanation

A. Brisk pupillary reaction to light: A brisk pupillary reaction to light is a normal neurological finding and does not indicate increased ICP. Increased ICP might present with a sluggish or unequal pupil response.

B. Irritability: Irritability is a common early sign of increased ICP in infants. Changes in behaviour, such as increased irritability or lethargy, can indicate a neurological problem, including increased pressure within the skull.

C. Tachycardia: Tachycardia (increased heart rate) is not a typical indicator of increased ICP. Bradycardia (decreased heart rate) is more commonly associated with increased ICP due to the pressure on the brainstem affecting autonomic functions.

D. Increased sensory response to painful stimuli: Increased sensory response is not typically indicative of increased ICP. In fact, as ICP worsens, a decrease in sensory response or altered level of consciousness is more likely.

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