Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Temperature 98.8° F (37.1° C)

Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic

Serum blood glucose 185 mg/dL (10.2 mmol/L)

White blood cell count 11.2 x 103/µL (11.2 x 109/L)

Capillary refill greater than 3 seconds bilateral lower extremities

Bilateral lower extremities skin warm, dry, and pink

Answer and Explanation

Correct Answer : A,D,F

Rationale:
A. Temperature 98.8° F (37.1° C): A normal body temperature indicates resolution of the infection and a positive response to antibiotic therapy for cellulitis. Fever reduction is a key indicator of therapeutic effectiveness.

B. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: While pain is low, the description of neuropathic pain unrelated to cellulitis does not reflect improvement in the infection itself, so it is not a primary indicator of therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although improved from the initial hyperglycemia, this level is still above the normal range. It does not directly indicate resolution of cellulitis or therapeutic effectiveness of antibiotic therapy.

D. White blood cell count 11.2 x 103/µL (11.2 x 10⁹/L): The decrease toward normal limits from an elevated WBC demonstrates a positive hematologic response to treatment and reduced systemic inflammation caused by the infection.

E. Capillary refill greater than 3 seconds bilateral lower extremities: Prolonged capillary refill indicates peripheral perfusion deficits. Persistent abnormal refill is not a sign of therapeutic response and may reflect ongoing vascular compromise.

F. Bilateral lower extremities skin warm, dry, and pink: Improvement in skin color, warmth, and absence of edema or erythema reflects resolution of cellulitis and effective local tissue recovery, consistent with therapeutic response.

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Correct Answer is B

Explanation

A. A potty chair should be brought from home to maintain the current level of toileting skills: While familiar items can offer comfort, regression in toileting is typically temporary and does not require special equipment to preserve skills.

B. Children usually resume their toileting behaviors when they leave the hospital: Hospitalization is a stressful event for preschoolers, and temporary regression in toileting is common. Reassuring parents that the child is likely to return to previous toileting behaviors once home helps reduce anxiety and supports normal developmental expectations.

C. Diapering will be provided since hospitalization is stressful to preschoolers: Diapering may be used for convenience or safety, but presenting it as necessary for all hospitalized children may cause unnecessary concern. It does not address the expected return to prior skills.

D. A retraining program will need to be initiated when the child returns home: Most children spontaneously resume previous toileting abilities without formal retraining. Only persistent regression after discharge would warrant intervention.

A. Risk for fluid and electrolyte imbalance. B. Disturbed body image related to loss of control. C. Imbalanced nutrition less than body requirements. D. Impaired coping related to excessive physical activity.

Correct Answer is C

Explanation

A. Risk for fluid and electrolyte imbalance: While important, this risk is secondary to the immediate physiological consequences of insufficient nutrition. Electrolyte imbalances often develop as a result of malnutrition and require close monitoring.

B. Disturbed body image related to loss of control: Body image disturbance is central to anorexia nervosa, but it does not pose an immediate threat to life. Psychological interventions are essential but follow stabilization of physical health.

C. Imbalanced nutrition less than body requirements: Inadequate nutrition directly threatens physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Restoring adequate nutrition is the highest priority to prevent life-threatening complications such as organ failure or severe electrolyte disturbances.

D. Impaired coping related to excessive physical activity: Excessive exercise may worsen malnutrition and stress, but it is secondary to the urgent need to correct nutritional deficits and stabilize the client’s physical condition.

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Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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Patient Data

Exhibits

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.