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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Using ibuprofen prophylactically to prevent febrile seizures is not a standard approach and is not generally recommended. The focus should be on managing the child's fever with appropriate fever-reducing medications rather than attempting to prevent febrile seizures with medication.

B. Reassure the parents that febrile seizures decrease as the child grows older.

Febrile seizures are relatively common in young children and are typically associated with rapid increases in body temperature, often due to infections.

The most important information to convey to the parents is that febrile seizures are usually a benign and self-limited condition, and they tend to decrease in frequency and may even resolve as the child grows older. Reassuring parents about the natural course of febrile seizures is vital to alleviate their concerns. However, it's essential to educate them on fever management and when to seek medical attention for their child's febrile seizures.

C. Avoiding excessive visual stimuli is not a standard recommendation for preventing febrile seizures. Febrile seizures are primarily related to fever and not visual stimuli.

D. Providing a sponge bath for temperatures over 100.6° F (38.1° C) can help reduce fever, but it is not directly related to preventing febrile seizures. The main goal in such situations is to manage the fever itself.

A. Jaundice. B. Chest pain. C. Swelling in the hands or feet. D. Ulcers on the legs

Correct Answer is B

Explanation

A. Jaundice is a common finding in individuals with sickle cell disease due to the breakdown of sickled red blood cells. While jaundice should be monitored and reported, it is not as immediately concerning as chest pain in the context of a sickle cell crisis.

B Chest pain.

Sickle cell disease is characterized by the presence of abnormal hemoglobin that can lead to the formation of sickled red blood cells. During a sickle cell crisis, these abnormal cells can block blood vessels, leading to tissue damage and severe pain. Chest pain in a child with sickle cell disease can be indicative of a potentially life-threatening complication called acute chest syndrome, which is a serious condition that requires immediate medical attention. Acute chest syndrome can lead to impaired oxygen exchange and respiratory distress, making it a medical emergency.

C. Swelling in the hands or feet can be associated with vaso-occlusive episodes in sickle cell disease, but it may not be as immediately concerning as chest pain.

D. Ulcers on the legs can be a complication of sickle cell disease, but they are not typically as acutely life-threatening as chest pain due to acute chest syndrome.

Chest pain should be treated as a medical emergency in a child with sickle cell disease during a sickle cell crisis, and the healthcare provider should be informed immediately to initiate appropriate intervention.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?

Correct Answer is B

Explanation

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?

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

The nurse is assessing a child with acute glomerulonephritis who presents to the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?

Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.