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The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.

Review H and P, laboratory results, flow sheet, and orders.

The nurse receives the report from the lab and documents the intake and output for 1600.

Based on the client's information at 1600, what symptoms should the nurse look for? Select all that apply.

Edema

Irritability

Fatigue

Dry skin

Intense thirst

Muscle weakness

Hypertension

Answer and Explanation

Correct Answer : A,D,E,F

A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.

D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.

E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.

F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.

B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.

The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.

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Free Nursing Study Resources

Correct Answer is ["A","D","F"]

Explanation

A - Maintaining a consistent home schedule is an essential strategy for managing ADHD, as routines and structure can help the child stay organized and focused.

B - Understanding that nonstimulant medications can also be beneficial in the treatment of ADHD is correct, as nonstimulant medications are an alternative or additional treatment option for some individuals with ADHD. It's important to have a comprehensive understanding of available treatment options.

C - The statement "Know that medication is the best approach to treatment" is not accurate. Medication can be an effective component of ADHD treatment, but it is not necessarily the best approach for every child. Treatment plans should be individualized and may include a combination of strategies, such as behavioral interventions, psychoeducation, and medication.

D - Creating an organization chart for tasks is a helpful approach for children with ADHD to manage their responsibilities and activities effectively.

E - Anticipating being automatically entered into a specialized education plan is not necessarily accurate. While some children with ADHD may benefit from an Individualized Education Plan (IEP) or a 504 Plan in the educational setting, these plans are typically established based on specific assessments and the child's needs.

F - Designating an established area for study is important for creating a distraction-free environment, which can support the child's ability to focus on their schoolwork.

A. Provide the parents with ideas about how to make their child feel better after the p B. ell the parents that the procedure is 100% effective and safe C. Limit visitation as long as the parents are anxious D. Find a comfortable area that the parents can wait that is close to the procedure an E. Do not give any specifics on the amount of time the procedure will take

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

Explanation

To help the parents decrease their anxiety, the nurse can:

A. Provide the parents with ideas about how to make their child feel better after the procedure. This can help reassure the parents that they can support their child during the recovery process.

D. Find a comfortable area that the parents can wait that is close to the procedure area. Being close to the procedure area allows the parents to stay informed and feel more connected to their child during the procedure.

E. Do not give any specifics on the amount of time the procedure will take. Providing a specific time may increase anxiety, so it's often better to provide a general idea of the timeframe.

Option B is not appropriate because stating that the procedure is 100% effective and safe may not be accurate and could lead to false expectations.

Option C is not appropriate because limiting visitation based on the parents' anxiety is not typically recommended. Supportive presence is generally encouraged for both the child and parents.

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Naxlex Comprehensive Predictor Exams

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement(s) made by the caregiver demonstrates an understanding of the education? (Select all that apply.)

Correct Answer is ["A","D","F"]

Explanation

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

Explanation

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?

A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment is most important for the nurse to obtain?

During her sports physical examination, a 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?