Which of the following findings indicate a potential complication that requires immediate follow-up? (Select All that Apply.)
Neurological assessment
Basic metabolic panel
Blood pressure/heart rate
Abdominal assessment
Complete blood count
Pain assessment
Correct Answer : A,B,C,E,F
A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.
B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.
C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.
D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.
E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.
F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Palliative care serves to hasten death and make the process easier for the family is an incorrect statement. Palliative care is focused on providing relief from symptoms and improving the quality of life, not hastening death.
B. Palliative care provides pain and symptom management and best quality of life for the child is the correct understanding of palliative care. It focuses on managing symptoms and providing support to improve quality of life, regardless of the child’s age or stage of illness.
C. The goal of palliative care is to place the child in a hospice setting at the end of life is not entirely correct. Palliative care can be provided at any stage of a serious illness, not just at the end of life, and it does not automatically mean placement in hospice.
D. The goal of palliative care is to act as the liaison between the family, child, and other health care professionals is a supportive role, but it does not fully define the scope of palliative care, which is focused on symptom management and improving quality of life.
Correct Answer is A
Explanation
A. Urine specific gravity 1.015 is correct. A specific gravity of 1.015 indicates good hydration status and that the child is effectively retaining fluids after oral rehydration therapy. Normal urine specific gravity ranges from 1.010 to 1.020.
B. Respiratory rate 24/min is not directly related to hydration status and does not necessarily indicate that rehydration therapy has been effective. It is a normal rate for a 3-year-old child, but respiratory rate alone isn't an indicator of fluid balance.
C. Heart rate 130/min is elevated for a 3-year-old child and may indicate dehydration or other stressors, suggesting that oral rehydration therapy has not been completely effective. A normal heart rate for this age is typically 80-120 beats per minute.
D. Capillary refill greater than 3 seconds is a sign of dehydration and poor perfusion, indicating that the oral rehydration therapy has not been effective in restoring hydration. Normal capillary refill time is less than 2 seconds.
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