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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

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Discontinue the ointment once drainage resolves.The ophthalmic antiinfective ointment should be used for the full prescribed duration, even if symptoms improve, to ensure the infection is completely treated and to prevent recurrence or resistance.

B. Remove secretions by wiping toward the opposite eye.Secretions should be removed by wiping away from the eye, from the inner canthus (near the nose) outward, to prevent spreading infection to the unaffected eye.

C. Use a disposable moist wipe to remove eye crusts.While it is important to keep the eye clean, the primary discharge instruction in this context should focus on the expected side effect of blurry vision.

D. Prepare child for blurry vision after ointment application:Ophthalmic antiinfective ointments can cause temporary blurry vision due to their consistency. Caregivers should be informed about this expected effect and reassured that it is temporary. This helps manage expectations and ensures adherence to the treatment plan.

A. "We should be sure to start our daughter on birth control pills." B. "Sexual maturity differences between my daughter and her peers will disappear within a few years." C. "Our daughter will be on this hormone treatment the rest of her life." D. "We should encourage her to dress in clothing that suits her sexual maturity level."

Correct Answer is B

Explanation

A. "We should be sure to start our daughter on birth control pills." This statement is not directly related to LHRH treatment for precocious sexual development. The primary goal of LHRH treatment is to delay sexual development, and birth control pills are typically not necessary for this purpose.

B. "Sexual maturity differences between my daughter and her peers will disappear within a few years."
In a case of precocious sexual development, treatment with luteinizing hormone-releasing hormone (LHRH) is often used to delay sexual development and slow down the maturation process. It is not typically a lifelong treatment. The primary goal is to allow the child to develop at a more typical pace, so they can catch up with their peers and avoid the psychosocial challenges associated with early sexual maturity. Therefore, the statement in option B indicates a correct understanding of the treatment, as it recognizes that the differences in sexual maturity between the child and her peers should diminish over time.

C. "Our daughter will be on this hormone treatment the rest of her life." This statement is not accurate. LHRH treatment is usually a temporary measure to delay sexual development. It is not a lifelong treatment.

D. "We should encourage her to dress in clothing that suits her sexual maturity level." While this is a consideration for supporting a child with precocious sexual development, the primary treatment aspect is the LHRH therapy itself, which is aimed at delaying sexual development. This statement does not directly address the treatment process.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic antiinfective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?

Correct Answer is D

Explanation

An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?

Correct Answer is B

Explanation

The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?

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

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?

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?