Which of the following findings should the nurse report to the health care provider immediately? (select all that apply)
Loss of appetite
Platelet count
Developmental regression
Absolute neutrophil count
Hemoglobin
Correct Answer : C,D
Choice A reason: Loss of appetite is not an urgent finding, as it may be caused by various factors, such as nausea, pain, or stress. The nurse should monitor the child's fluid and calorie intake and encourage oral hydration and nutrition. However, loss of appetite does not require immediate reporting to the health care provider.
Choice B reason: Platelet count is not an urgent finding, as it is not given in the text. The nurse should check the child's laboratory results and compare them with the normal ranges for preschoolers. A normal platelet count for children is 150,000 to 450,000 per microliter of blood¹. A low platelet count (thrombocytopenia) may indicate bleeding disorders, infections, or bone marrow problems. A high platelet count (thrombocytosis) may indicate inflammation, infection, or cancer. The nurse should report any abnormal platelet count to the health care provider, but it is not an immediate concern.
Choice C reason: Developmental regression is an urgent finding, as it may indicate a serious neurological problem, such as a brain tumor, infection, or injury. Developmental regression is the loss of previously acquired skills or milestones, such as language, motor, or social skills. The nurse should assess the child's developmental level and report any signs of regression to the health care provider as soon as possible.
Choice D reason: Absolute neutrophil count is an urgent finding, as it may indicate a severe infection or a compromised immune system. Neutrophils are a type of white blood cell that fight bacterial infections. The absolute neutrophil count is the number of neutrophils in a microliter of blood. A normal absolute neutrophil count for children is 1,500 to 8,000 per microliter of blood². A low absolute neutrophil count (neutropenia) may increase the risk of infection and sepsis. A high absolute neutrophil count (neutrophilia) may indicate an acute infection or inflammation. The nurse should report any abnormal absolute neutrophil count to the health care provider immediately.
Choice E reason: Hemoglobin is not an urgent finding, as it is not given in the text. The nurse should check the child's laboratory results and compare them with the normal ranges for preschoolers. Hemoglobin is a protein in red blood cells that carries oxygen. A normal hemoglobin level for children is 11.5 to 15.5 grams per deciliter of blood³. A low hemoglobin level (anemia) may indicate blood loss, iron deficiency, or bone marrow problems. A high hemoglobin level (polycythemia) may indicate dehydration, lung disease, or heart disease. The nurse should report any abnormal hemoglobin level to the health care provider, but it is not an immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct instruction for the nurse to include in the plan. Mumps is a viral infection that causes inflammation of the salivary glands. It is transmitted by respiratory droplets from coughing, sneezing, or talking. The nurse should initiate droplet precautions, which include wearing a surgical mask, gloves, and gown, and keeping the child in a private room or with other children who have mumps.
Choice B reason: This is not the correct instruction for the nurse to include in the plan. Airborne precautions are used for infections that are transmitted by small particles that can remain suspended in the air for long periods of time, such as tuberculosis, chickenpox, or measles. Mumps is not an airborne infection, and the nurse does not need to wear a respirator or place the child in a negative pressure room.
Choice C reason: This is not the correct instruction for the nurse to include in the plan. Contact precautions are used for infections that are transmitted by direct or indirect contact with the infected person or their environment, such as scabies, impetigo, or MRSA. Mumps is not a contact infection, and the nurse does not need to wear gloves and gown for all interactions with the child or use disposable equipment.
Choice D reason: This is not the correct instruction for the nurse to include in the plan. Standard precautions are the minimum level of infection control that should be used for all patients, regardless of their diagnosis or presumed infection status. They include hand hygiene, use of personal protective equipment, safe injection practices, and environmental cleaning. However, they are not sufficient for preventing the transmission of mumps, and the nurse should use additional precautions.
Correct Answer is A
Explanation
Choice A reason: Rice is a suitable food choice for a child who has celiac disease, as it is a gluten-free grain that does not cause inflammation or damage to the small intestine. Rice can provide carbohydrates, fiber, and vitamins for the child's nutrition.
Choice B reason: Rye is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Rye can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Choice C reason: Wheat is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Wheat can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Choice D reason: Barley is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Barley can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
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