The nurse has reviewed the Nurses' Notes, the Vital Signs at 1000 and 1030, and the Laboratory Results at 1030.
Complete the following sentence by using the lists of options.
The nurse should first address the adolescent's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices:
• Blood pressure: The adolescent’s blood pressure dropped from 116/60 mm Hg to 88/50 mm Hg, indicating hypotension and potential septic shock. This is a life-threatening complication of meningococcal meningitis and requires immediate intervention to maintain perfusion.
• Temperature: The adolescent has a fever of 39° C (102.2° F), which contributes to metabolic stress and worsens neurologic symptoms. Once circulation is stabilized, managing hyperthermia helps decrease cerebral metabolic demand and discomfort.
Rationale for incorrect choices:
• Respiratory status: The respiratory rate and oxygen saturation are stable, with no signs of distress. This is not the most urgent priority compared to hypotension and shock risk.
• CSF results: While the findings are abnormal and confirm bacterial meningitis, they guide long-term treatment but do not pose an immediate threat like shock or hyperthermia.
• Oxygen saturation: Respirations remain 20/min with clear breath sounds and stable oxygen saturation, so there is no current evidence of respiratory compromise requiring immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","F","G","H"]
Explanation
Rationale:
• Respiratory rate 26/min: A respiratory rate in the mid-20s is within the normal range for toddlers (20–30/min). The child shows no increased work of breathing, so this does not require immediate intervention.
• Heart rate 112/min: This heart rate falls within the normal toddler range of 90–140 beats per minute. It does not indicate tachycardia or circulatory collapse at this time. Therefore, it is not a priority concern.
• Capillary refill 4 seconds: A refill time greater than 2 seconds indicates impaired circulation and reduced tissue perfusion. This is often seen in dehydration or hypovolemic shock, requiring immediate intervention. Prolonged refill signals worsening cardiovascular compromise.
• Hyperactive bowel sounds: Increased bowel sounds are expected in the setting of diarrhea and rapid peristalsis. While uncomfortable, this finding is not life-threatening and does not require urgent follow-up.
• Diaper area reddened: Redness in the diaper area is most likely due to frequent stools causing skin irritation. While it requires nursing care, it is a localized issue and not an urgent systemic concern.
• Extremities cool: Cool extremities suggest peripheral vasoconstriction as the body tries to preserve blood flow to vital organs. This points to inadequate perfusion from fluid loss. If not addressed quickly, it may progress to shock.
• Reports no tears: Crying without tears is a clear sign of moderate to severe dehydration in children. It indicates the body no longer has adequate fluid reserves to maintain normal secretions. This finding requires prompt replacement of fluids.
• Lethargic: Lethargy signals a change in neurological status, which is a late sign of significant dehydration. It reflects decreased cerebral perfusion from hypovolemia. This is a critical finding that warrants urgent follow-up.
Correct Answer is D
Explanation
A. Reschedule the procedure until the client's guardian provides written consent: In most states, adolescents have the legal right to consent to reproductive health services, including contraception. Guardian consent is not required for IUD insertion.
B. Call the adolescent's guardian to obtain verbal consent prior to the procedure: Involving a guardian without the adolescent’s permission breaches confidentiality. Reproductive health decisions are protected for adolescents, and verbal consent from a guardian is unnecessary.
C. Encourage the adolescent to wait to ask questions about the device until after its insertion: It is essential for the adolescent to receive complete education and have all questions answered before the procedure. Informed consent cannot be obtained after the procedure has already been done.
D. Witness the adolescent's signature on the consent form: Adolescents can legally provide consent for contraception. The nurse’s role is to witness the signature, ensuring the adolescent understands the procedure and that the consent is voluntary.
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