The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

Lethargy and hypotonia

Elastic skin turgor

Apical heart rate = 64 beats per minute

Blood pressure = 100/54 mmHg

Flat anterior fontanel

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Lethargy and hypotonia are critical findings in a child who was left in a closed car. These symptoms can indicate severe dehydration, heat stroke, or other serious conditions that require immediate medical attention.

Choice B reason: Elastic skin turgor generally indicates good hydration status and is not an immediate concern that needs to be reported urgently in this context.

Choice C reason: An apical heart rate of 64 beats per minute is significantly low for a 14-month-old child, indicating bradycardia, which can be a sign of severe heat stress or dehydration. This finding needs immediate reporting.

Choice D reason: A blood pressure of 100/54 mmHg is within the normal range for many paediatric patients, but in the context of being left in a hot car, it can suggest potential complications and should be monitored closely. However, it is not as critical as the heart rate and mental status findings.

Choice E reason: A flat anterior fontanel is a normal finding in infants and does not require urgent intervention in this context.

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Correct Answer is D

Explanation

Choice A reason: Having the caregivers in the room with the patient may not provide a confidential and comfortable environment for the 16-year-old. Adolescents may feel embarrassed or reluctant to discuss sensitive issues related to sexually transmitted infections (STIs) in front of their caregivers. This approach does not fully support patient-cantered care, which focuses on respecting the patient’s privacy and promoting open communication.

Choice B reason: Providing written reading materials is an important aspect of education, but it may not be sufficient on its own to ensure that the patient fully understands the information. Reading materials should be supplemented with personalized discussion to address specific concerns and questions the patient may have. Therefore, while helpful, this intervention alone does not represent the most patient-cantered approach.

Choice C reason: Educating the patient to avoid sexual activity is a limited approach that does not consider the complexities of an adolescent's experiences and needs. A more patient-cantered approach would involve discussing safe sexual practices, STI prevention methods, and empowering the patient with comprehensive information to make informed decisions about their sexual health, rather than simply advising abstinence.

Choice D reason: Assessing the patient alone provides a private and supportive environment where the 16-year-old can feel more comfortable discussing sensitive topics. This approach respects the patient’s autonomy, ensures confidentiality, and allows for more open and honest communication. It demonstrates a commitment to patient-cantered care by addressing the individual needs and concerns of the patient.

A. Salmeterol B. Prednisone C. Ibuterol D. Par

Correct Answer is A

Explanation

Choice A reason: Salmeterol, a long-acting beta-agonist (LABA), is generally not recommended for use during pregnancy due to potential risks to the fetes. It is typically avoided unless absolutely necessary and other safer options are not effective.

Choice B reason: Prednisone is a corticosteroid that can be used during pregnancy when necessary. It is often prescribed for managing severe asthma symptoms, but it should be used under close medical supervision to minimize potential risks.

Choice C reason: Ibuterol is a short-acting beta-agonist (SABA) and is generally considered safe for use during pregnancy. It is commonly used as a rescue inhaler to relieve acute asthma symptoms.

Choice D reason: The text for option D is incomplete and does not provide sufficient information to determine its relevance to the question.

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The emergency department nurse is assessing a 14-month-old child who was left inside a closed car for an hour. The outside temperature was 88 degrees Fahrenheit. Which assessment findings will the nurse report immediately to the health care provider? Select all that apply.

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