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Exhibits

The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.

A.

Dyspnea

B.

Heart rate

C.

Blood pressure

D.

Oxygen saturation

E.

Respiratory rate

F.

Oral intake

G.

Lung sounds

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Assessment Finding

Improved

No change

Dyspnea

 

✅

Heart rate

✅

 

Blood pressure

✅

 

Oxygen saturation

✅

 

Respiratory rate

✅

 

Oral intake

✅

 

Lung sounds

 

✅

Rationale:

Improved:

Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.

Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.

No change:

Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.

Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.


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Related Questions

Correct Answer is C

Explanation

A. Lack of eye contact can indicate a developmental concern, but it is not specific to hearing impairment.

B. Lack of gesturing by 15 months could be concerning, but it is more related to social development than to hearing.

C. By 7 months, infants should begin babbling. The absence of babbling at this age is a red flag for potential hearing issues.

D. The absence of the Moro reflex is expected after the first few months of life, so it is not a sign of hearing impairment.

Correct Answer is ["A","C","E"]

Explanation

2100: Child brought into the emergency department by their guardians. The child has Acute Lymphoblastic Leukemia (ALL) and is currently in the induction phase of treatment for standard risk. The child received chemotherapy with vincristine 8 days ago and is taking daily oral steroids. Child is alert, crying, and clinging to guardian. Guardians report the child has not had a bowel movement for 5 days.

2100:

Pulse 120/min

Respiratory rate 25/min

Temperature 38.8° C (101.9° F) tympanic

SaO2 96% on room air

2120: Child now asleep in guardian's arms. Respirations unlabored, heart rate regular. Child has a double-lumen central line catheter in the left chest wall. Insertion site is erythematous with a scant amount of purulent drainage.

Rationale:

Temperature of 38.8°C (101.9°F) tympanic: Fever in a child with leukemia is concerning as it may indicate an infection, especially since the child is immunocompromised due to chemotherapy. This needs immediate follow-up and potentially blood cultures to determine the source of infection.

Erythema and purulent drainage at central line insertion site: Purulent drainage and erythema at the central line insertion site suggest a possible infection, such as a catheter-associated bloodstream infection. This requires prompt follow-up, possibly including antibiotic therapy and further investigations to prevent sepsis.

Child has not had a bowel movement for 5 days: Constipation is a common side effect of chemotherapy and oral steroids, but a delay in bowel movements could indicate bowel obstruction or other gastrointestinal issues. This needs to be addressed, and the child may require laxatives or further investigation.

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