Exhibits

The nurse reviews the electronic health record.

Highlight the finding(s) that require the nurse's attention. Select all that apply.

Heart rate 88 beats/minute

Blood pressure 122/72 mm Hg

Temperature 100.5° F (38° C)

Reports of pain with ambulation

Respirations 20 breaths/minute

Left lower leg with erythema, warm, and swollen

Blood glucose 252 mg/dL (13.9 mm

Instruct incentive spirometry use every hour (Nonessential): There is no indication of respiratory compromise, so incentive spirometry is not a priority for this client.

Encourage consumption of protein and vitamin C (Indicated): These nutrients support wound healing and immune function, which are important in managing infection and preventing further complications.

Apply thromboembolism deterrent stockings (TED) (Contraindicated): TED stockings may worsen symptoms if the client has cellulitis or a deep vein thrombosis (DVT), as compression can increase pain and impede circulation in an already swollen and inflamed limb.

Use petroleum-based lotion on legs (Contraindicated): Petroleum-based products can trap moisture and create an environment for bacterial growth, which is not suitable for a client with cellulitis or diabetes. Instead, a diabetic-safe moisturizer should be used while avoiding open wounds.

A. Explain that the child is likely to grow into her weight. This is incorrect because a BMI at the 85th percentile indicates that the child is overweight. Without intervention, the risk of continued excess weight gain and future obesity increases.
B. Obtain the child's 3-day diet history based on the mother's input. Assessing the child's dietary habits helps identify potential areas for improvement, such as reducing sugary drinks or increasing fruit and vegetable intake. Understanding the child’s nutrition is essential for developing a healthy eating plan.
C. Tell the mother that girls hit their growth spurt before boys so eating more is expected. While girls do experience growth spurts earlier than boys, this does not justify excessive weight gain. Encouraging healthy eating and physical activity is more appropriate than assuming the child will "grow out of it."
D. Inquire as to whether or not the school has a physical education program. School-based physical activity plays an important role in weight management. If the school lacks a structured program, additional strategies for physical activity should be explored.
E. Determine the child's usual physical activity pattern. Assessing the child’s activity level helps identify if sedentary behaviors (e.g., excessive screen time) are contributing to weight gain. Encouraging regular physical activity is a key part of managing childhood obesity.