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Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The client is at risk for developing

as evidenced by.
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Rationale for Correct Choices:

  • Seizures: The adolescent’s fever, headache, photophobia, and neck stiffness (resistance to flexion) are consistent with signs of meningitis, which can lead to seizures, especially in the setting of increased intracranial pressure. Seizures are a known complication of untreated or severe meningitis.
  • Signs of meningeal irritation: The adolescent demonstrates classic signs of meningeal irritation, such as photophobia, severe headache, and neck stiffness, which suggest inflammation of the meninges. This is a key indicator of potential meningitis and the associated risk of seizures.

Rationale for Incorrect Choices:

  • Lyme disease: While Lyme disease can cause neurological symptoms, including headache and fever, the absence of a characteristic erythema migrans rash or recent tick exposure makes it less likely.
  • Constipation: Constipation is not a likely complication given the adolescent's current symptoms, which are focused on fever, headache, and neurological signs. It does not explain the risk for seizures.
  • Mononucleosis: Although mononucleosis can cause fever and malaise, it typically does not present with neck stiffness, photophobia, or the acute onset of severe headache that is suggestive of meningitis. The symptoms in this case are more concerning for meningitis.
  • Pneumonia: Pneumonia is unlikely given the absence of respiratory findings such as cough or difficulty breathing. The symptoms are more consistent with a central nervous system infection, like meningitis, than a respiratory infection.
  • Fever: While fever is present in meningitis, it alone does not indicate the risk for seizures. It is the combination of fever, headache, photophobia, and meningeal signs that increases the risk for complications like seizures.
  • Inability to eat and drink: The inability to eat and drink is likely a result of nausea and vomiting, which is common in many illnesses, including meningitis. However, it is not a direct indicator of the risk for seizures, which is more strongly linked to meningeal irritation.
  • Respiratory findings: There are no significant respiratory symptoms, such as difficulty breathing or abnormal lung sounds, making respiratory findings irrelevant in this case. The adolescent’s symptoms are primarily neurological.


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Related Questions

Correct Answer is D

Explanation

A. Maintain the child in a supine position: The child should not be in a supine (lying flat) position during enteral feedings, as this increases the risk of aspiration. The child should be positioned upright or at least 30 to 45 degrees to reduce this risk.
B. Discard gastric residuals prior to each feeding: While it is important to check gastric residuals before each feeding to ensure proper gastric emptying, residuals should not automatically be discarded. Depending on the volume of residuals, the feeding may need to be delayed or adjusted rather than discarded.
C. Warm the feeding in the microwave oven for 15 seconds: Feeding should never be warmed in the microwave because it can cause uneven heating, which could lead to burns. Feedings should be warmed using a safe method, such as a warm water bath, to ensure even temperature.
D. Administer the feeding to the child at 10 mL/min: Administering the feeding at a slow and controlled rate, such as 10 mL/min, is recommended to prevent discomfort and reduce the risk of aspiration. This rate allows the digestive system to process the feeding properly.

Correct Answer is C

Explanation

A. Short stature: Short stature is not a common adverse effect of budesonide when used as an inhaler. However, long-term use of inhaled corticosteroids in children may have a small effect on growth, but it is not a primary concern with budesonide.
B. Weight loss: Weight loss is not associated with the use of an inhaled corticosteroid like budesonide. Weight gain or fluid retention may be more common with systemic steroids, but this is less of a concern with inhaled forms.
C. Oral candidiasis: Oral candidiasis (thrush) is a known side effect of inhaled corticosteroids, including budesonide. This occurs due to the medication's impact on the oral mucosa, which can promote fungal growth. To reduce the risk, the child should rinse their mouth after using the inhaler.
D. Peptic ulcer: Peptic ulcers are more commonly associated with systemic corticosteroids, not with inhaled corticosteroids like budesonide. Although systemic absorption can occur, the risk for ulcers is significantly lower with inhaled forms compared to oral or injected steroids.

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