Four days after exposure to COVID-19 a client has a negative COVID-19 test result. Eight days after the negative test result, the client presents with fever, fatigue, and cough and the nurse performs a second COVID-19 test. Which action is most important for the nurse to take?

Rationale:

A. "Are you the type of person who shares your problems easily?": This question explores communication style but may feel invasive or irrelevant to someone in acute distress. It does not directly address the client’s current emotional needs or offer support.

B. "What do you think is your primary goal to achieve this time?": Goal setting is important during the planning phase of care, but clients in overwhelming anxiety may not be ready for structured thinking. This question may increase pressure and exacerbate anxiety.

C. "Would you like me to sit with you for a while?": This offers immediate emotional support and conveys presence, which helps build trust and reduce anxiety. It is a therapeutic approach that meets the client’s most urgent need for calm and reassurance.

D. "Have you experienced changes in your life recently?": Life changes may contribute to anxiety, but exploring them is appropriate after the client feels emotionally safe and stable. The initial priority is to establish a calming presence, not to probe background stressors.

Rationale for Correct Choices

• Intussusception: This condition is common in young children and is characterized by intermittent, severe abdominal pain, vomiting, and blood-streaked or "currant jelly" stools. The child's posture (knees to chest), pain pattern, and bloody stool strongly point to intussusception.
• Place a nasogastric tube: An NG tube helps decompress the bowel and relieve symptoms such as vomiting and abdominal distension, which are common in intussusception. It also prevents aspiration while awaiting treatment.
• Prepare the child for surgery: If non-surgical reduction (e.g., air enema) fails or the bowel is compromised, surgical intervention is required. Preparing for surgery is appropriate due to the severity of symptoms.
• Abdominal girth: Measuring abdominal girth helps detect increasing distension, which could indicate worsening obstruction, perforation, or edema—serious complications of intussusception.
• Stool color: Stool color should be closely monitored to assess resolution of the obstruction. Return to normal brown stools suggests successful reduction of the intussusception.

Rationale for Incorrect Choices

• Irritable bowel syndrome: IBS is rare in children and does not typically present with vomiting, bloody stool, or acute severe pain. It's a chronic condition with milder, recurring symptoms.
• Acute hepatitis: Hepatitis presents with jaundice, malaise, and abdominal discomfort, not acute, colicky pain, vomiting, or bloody stools. It's also uncommon in this age group without risk factors.
• Gastroesophageal reflux: GERD involves regurgitation or vomiting but not bloody stool or severe abdominal pain. The child’s pain pattern and blood in stool make this unlikely.
• Place the child in Trendelenburg position: This position is not recommended in abdominal emergencies like intussusception, as it can worsen intra-abdominal pressure and discomfort.
• Provide ice chips: The child is NPO (nothing by mouth) due to the risk of surgery and aspiration. Ice chips are contraindicated.
• Administer a glycerin suppository: Constipation is not the issue; glycerin would not resolve intussusception and could worsen the situation or delay definitive treatment.
• Urine output: Although important in general assessment, it is less specific for tracking the resolution of intussusception compared to stool color and abdominal girth.
• Platelet count: Not a primary concern in intussusception unless there’s an unrelated bleeding or clotting disorder.
• Bleeding: Monitoring for active bleeding is not a priority in intussusception unless signs of massive hemorrhage appear, which is rare. Stool monitoring gives more specific clues.