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Exhibits

Nurses' Notes

Day 4, 0905:

Child is resting comfortably in bed. Alert and oriented to time, place, and person. Caregivers report child has been interactive and showing increased interest in eating. Child engages with staff and caregivers appropriately for age. No headache and no pain reported during neck flexion. Brudzinski and Kernig signs are negative. Mucous membranes are moist. Skin is warm, without cyanosis and capillary refill is less than 2 seconds. Pupils are equal round and reactive to light accommodation, with no squint observed in room lighting Lungs clear to auscultation. S, and S2 heard without murmurs. Abdomen is soft and nontender, with hypoactive bowel sounds in all quadrants.

Vital Signs

Day 4, 0905:

Temperature 37° C (98.6° F)

Heart rate 90/min Respiratory rate 22/min

Blood pressure 105/68 mm Hg

Oxygen saturation 98% on room air

Weight 20 kg (44 lb)

A. Airborne precautions are not required for gentamicin administration, as this medication does not pose a risk of airborne transmission. Gentamicin is an antibiotic, and precautions depend on the infection being treated, not the medication itself.

B. Maintaining strict intake and output is essential when administering gentamicin because it can be nephrotoxic. Monitoring fluid balance helps detect early signs of kidney impairment, allowing timely intervention to prevent further damage.

C. Constipation is not a common adverse effect of gentamicin; gastrointestinal symptoms are more often nausea or vomiting. Monitoring bowel function is important but less critical than kidney function with this medication.

D. Encouraging bed rest is not a standard nursing action specifically related to gentamicin administration. Mobility should be maintained as tolerated to prevent complications like thrombosis unless contraindicated by the patient’s condition.

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.