The nurse is reviewing the history and physical notes, as well as the nurse’s notes and laboratory results for a child.
The child is developmentally appropriate, interacting with his parents, and is in the percentile for weight and height.
The child’s lung sounds are clear and equal, a murmur is noted upon auscultation, and clubbing of the fingers is observed.
There is no skin breakdown, and the mucous membranes are pink and moist.
What condition is the child most likely experiencing, what two actions should the nurse take for this condition, and what two parameters should the nurse monitor to assess the child’s progress?

Choice A rationale

Watery diarrhea is a significant side effect of linezolid and could indicate a serious condition called antibiotic-associated colitis, which is caused by an overgrowth of the bacterium Clostridium difficile. This condition requires immediate medical attention.

Choice B rationale

Increased fatigue is a common side effect of many medications, including linezolid. While it should be reported to the healthcare provider, it is not as urgent as watery diarrhea.

Choice C rationale

Nausea and headache are common side effects of linezolid. While they should be reported to the healthcare provider, they are not as urgent as watery diarrhea.

Choice D rationale

Yellow-tinged sputum could indicate an infection or other lung condition. However, in the context of a patient receiving linezolid for nosocomial pneumonia, it is not as urgent as watery diarrhea.

Choice A rationale

The patient was able to sleep through the night. This is a positive sign as it indicates that the patient is comfortable and not in distress. Sleep is essential for healing and recovery.

Choice B rationale

The patient’s left arm is warm to touch. This could indicate that there is adequate blood flow to the area, which is necessary for healing. However, warmth could also be a sign of inflammation or infection, so it’s important to monitor this closely.

Choice C rationale

The patient’s left shoulder and collarbone are symmetric. This is a good sign as it indicates that there is no obvious dislocation or fracture, which could cause pain and limit mobility.

Choice D rationale

The patient has no desire to eat breakfast. This is not necessarily a sign of progress. Loss of appetite can be a symptom of many conditions, including stress, infection, or certain medications. It’s important to encourage the patient to eat to maintain strength and support healing.