A Nurse in an Emergency Department is Caring for a School

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? Administer epinephrine IM Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately it causes decreased blood return to the hfour childreneart. We have an expert-written solution to this problem! A nurse in a pediatric emergency department is planning care for an adolescent. Based on the information in the adolescent's medical record, which of the following actions should the nurse plan to take? Select all that apply. Apply supplemental oxygen Rationale: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. Also according to the medical record and chest x-ray report, the adolescent's oxygen saturation level is decreasing, which indicates hypoxia. Therefore, the nurse should plan to administer supplemental oxygen. Prepare for chest tube insertion Rationale: According to the medical record and chest x-ray report, the adolescent could potentially have a pneumothorax. A pneumothorax is the presence of air in the pleural cavity, which results in decreased lung expansion. The adolescent could experience dyspnea, tachypnea, tachycardia, hypoxia, and pain. This requires prompt intervention by the provider, such as the placement of a chest tube into the thoracic cavity to remove air and fluid from the pleural space, if present, allowing the lung to re-expand. A nurse in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? Monitor the child's oxygen saturation Rationale: The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. A nurse is providing teaching about play activities for social development to the guardians of a preschooler. Which of the following play activities should the nurse recommend for the child? Playing dress-up Rationale: The nurse should instruct the guardians that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child. A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? A school-age child who has sickle cell anemia and reports decreased vision in the left eye Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first. A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? "Brush the child's teeth after giving the medication." Rationale: The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste. A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? Zinc oxide Rationale: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. A nurse is caring for a client who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site. A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the biceps reflex. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? Screen the child's visitors for indications of infection. Rationale: A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection. A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? "Shake the medication prior to administration." Rationale: The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension. A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? "Mononucleosis is caused by an infection with the Epstein-Barr virus." Rationale: The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? Provide small, frequent meals for the child. Rationale: The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy. A nurse is providing anticipatory guidance to the guardian of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? Expresses likes and dislikes Rationale: The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The guardian should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions. A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority? Disease process Rationale: The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure? Administer an analgesic to the child. Rationale: Hydrotherapy for debridement of a wound is an extremely painful procedure that requires analgesia and/or sedation. Controlling pain leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder. A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? "I should keep my child indoors when I mow the yard." Rationale: The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks. A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? ½ cup raisins Rationale: The nurse should encourage the adolescent to eat raisins because they contain the highest amount of non-heme iron. A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? "Encourage the child to perform independent self-care." Rationale: The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? Apply topical analgesic cream to the site 1 hr prior to the procedure. Rationale: The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted. A nurse in the outpatient pediatric clinic is caring for a 2-year-old child. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again. Nurses' Notes - 2 months ago: The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currently being renovated, about 6 months ago. Parent reports having difficulty getting When recognizing cues, the nurse should identify that pale pink mucous membranes, living in an older urban house that is being renovated, and the parent's report that the toddler seems less active and gets tired more quickly are findings that require follow-up. These findings are associated with lead poisoning, and the child's blood lead level should be determined. Pale pink membranes, decreased activity, and tiring more quickly are manifestations of anemia, which can result from increased blood lead levels. Older urban homes are a common source of lead, especially during renovation, which may aerosolize the lead particles. A nurse in the outpatient pediatric clinic is caring for a 2-year-old child. Drag words from the choices below to fill in each blank in the following sentence. Nurses' Notes - 2 months ago: The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currently being renovated, about 6 months ago. Parent reports having difficulty getting the toddler to Nurses' N When analyzing cues, the nurse should identify that the child is a risk for developing intellectual deficits, such as a decreased IQ, due to the increase in membrane permeability of the brain tissue resulting in increased intracranial pressure, tissue ischemia, and atrophy. The nurse should also identify that the child is at risk for decreased kidney function due to the damage of the proximal tubules caused by the elevated blood lead level. The nurse has reviewed the child's nurses notes, assessment, vital signs, providers prescriptions and laboratory results for the 0800 one month ago visit. Complete the following sentence by using the lists of options. The nurse should first address the child's __________, followed by the child's __________. Nurses' Notes - 2 months ago: The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports mo When prioritizing hypotheses, the nurse should first address the child's elevated BLL, followed by the child's hemoglobin. Using the priority framework of safety and risk reduction, the nurse should recognize that the child's BLL presents an increased risk for long-term cognitive impairment and behavioral issues and should be addressed first. Lead interferes with heme synthesis, which causes anemia, as evidenced by the child's low hemoglobin. Addressing the lead level first will cause the hemoglobin level to improve. Kidney damage (ketonuria and glycosuria) is reversible once the lead level has been addressed. The nurse has reviewed the child's nurses notes, assessment, vital signs, providers prescriptions and laboratory results for the 0800 one month ago visit. The nurse is planning care for the child. For each potential provider prescription, click to specify if the prescription is anticipated or contraindicated for the client. Nurses' Notes - 2 months ago: The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The p When generating solutions, the nurse should ANTICIPATE the provider to prescribe medications (succimer, ferrous sulfate) and consults for a dietitian and Social Services. Succimer is a chelating agent that is used in children who have blood lead levels of greater than 45 mcg/dL and are asymptomatic. The nurse should anticipate a prescription for ferrous sulfate to treat the anemia that has developed due to increased blood lead levels. The nurse should anticipate a consult from Social Services to assist the parent in finding housing until the renovations are completed and to identify other needed resources. The nurse should anticipate consulting a dietitian to assist the parent in providing meals that are high in iron and calcium and low in fat. These foods are important for the child to consume to diminish the effects of lead poisoning. Chelating agents, such as succimer, are eliminated from the body through the kidneys. It is necessary that the child remains well hydrated during ch The nurse has reviewed the provider prescriptions for the 0900, 1 month ago visit. The nurse is providing discharge teaching to the parent. Which of the following information should the nurse include? Select all that apply. Nurses' Notes - 2 months ago: The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currently being renovated, about 6 months ago. P When taking action, the nurse should include in the discharge teaching to open the succimer capsule and sprinkle on 1 tsp of applesauce. A 2-year-old child is unable to swallow a capsule, and this capsule is not an extended- or time-release capsule. Therefore, opening the capsule and sprinkling the contents on a small amount (1 teaspoon) of pleasurable food will assist in the administration of the medication. A wet cloth should be used to dust. This prevents the spread of lead-containing particles. The parent should give the ferrous sulfate elixir using a straw to prevent staining of the teeth. Offering orange juice or a drink containing high levels of ascorbic acid when administering ferrous sulfate can increase the absorption of iron. The parent should monitor the number of wet diapers. It is important that the child stay hydrated during treatment with succimer to prevent renal toxicity. The parent should prevent the child from playing in soil near the house, which most likely is con The nurse has reviewed the child's nurses notes, assessment, vital signs, providers prescriptions and laboratory results for today's visit. Which of the following conditions are improving since the child's visit 1 month ago? Select 4 of the following conditions. Nurses' Notes - 2 months ago: The toddler is here for their well-child visit and is accompanied by a parent. Toddler is active, alert, and walking without assistance. The parent reports moving to an older urban house, which is currentl When evaluating outcomes, the nurse should identify an improvement in the child's health based on the findings of lead poisoning, kidney function, exposure to lead, and nutritional status. The BLL has decreased since the previous visit in response to the chelating medication. This indicates a decrease in the amount of lead in the body. The amount of glucose in the urine has decreased, which shows an improvement in the damage to the proximal tubules of the kidneys. Exposure to lead has decreased. The parent reports no longer residing in the older home that is being renovated, which was a source of lead exposure to the child. The nutritional status has improved based on parent's report of the child eating better and consuming more calcium-rich foods. Also, the child's weight has increased since the previous visit. A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? Hematocrit 28% Rationale: The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Provider Prescriptions?Tuberculin skin test (TST)Measles, mumps, and rubella (MMR) vaccineInactivated influenza vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine? Graphic Re Withhold the measles, mumps, and rubella (MMR) vaccine. Rationale: The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine. A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? Initiate IV access Rationale: After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume. A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? Serum creatinine 3.0 mg/dL Rationale: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? Schedule the toddler for a yearly re-screening. Rationale: The nurse should schedule the toddler for a lead level re-screening in 1 year and educate the family on ways to prevent exposure. A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? (You will find "hot spots" to select in the artwork below. Select only the hot spot that corresponds to your answer.) A Rationale: The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness. A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? Presence of strabismus Rationale: Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. We have an expert-written solution to this problem! A nurse is caring for a preschooler who has neutropenia. Which of the following statements should the nurse make to the child's guardians? "Avoid using your child's daycare center." Rationale: Children who have neutropenia are immunocompromised and susceptible to infection. Therefore, places where large groups of people gather, such as daycare centers, should be avoided. A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? Serum potassium level 4.1 mEq/L Rationale: The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? Initiate droplet precautions for the child. Rationale: The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks. A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? "I will monitor my child's number of wet diapers." Rationale: The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? Sodium 155 mEq/L Rationale: A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take? Assess peripheral pulses once every 4 hr. Rationale: Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling. A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? Symmetric burns of the lower extremities Rationale: The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron. A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? The child should be able to stand on the balls of their feet when sitting on the bike. Rationale: To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar. A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? Cuts an outlined shape using scissors Rationale: The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape. A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? Absence of peristalsis Rationale: The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning. A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? Have the adolescent sign a consent form for treatment. Rationale: The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Graphic Record Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) Nurses' Notes 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formul Episodes of vomiting Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain? Allow the mother to breastfeed while the sample is being obtained. Rationale: The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants. A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? Avoid palpating the abdomen when bathing the child before surgery. Rationale: The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? Implement seizure precautions for the infant. Rationale: An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? Explore the parents' feelings and wishes regarding organ donation. Rationale: The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family. A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? Dry, hacking cough Rationale: The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night. A nurse is caring for a preschooler whose guardian is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their guardian will return? "Your guardian will be back after you eat." Rationale: Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating. A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? Erythrocyte sedimentation rate 18 mm/hr Rationale: The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. A nurse on a pediatric unit is caring for a school-age child. After reviewing the information in the child's medical record, which of the following findings should the nurse address first? Complete the following sentence by using the list of options. The nurse should first address the child's _________ followed by the child's _________. Diagnostic Results CBC: Hemoglobin 8.0 g/dL (10 to 15.5 g/dL) Hematocrit 28% (32% to 44%) RBC count 4.2 million/mm3 (4 to 5.5 million/mm3) WBC count 12,000/mm3 The nurse should first address the child's oxygen saturation followed by the child's pain. Rationale: The child's pulse oximeter reading is below the expected reference range. The nurse should take action to maintain the child's oxygen saturation above 95%. When using the urgent vs. non-urgent approach to client care, the nurse should identify that addressing the child's hypoxia is the priority intervention. Rationale: The child reported their pain as 8 on a scale of 0 to 10, which indicates severe pain. Vasoocclusive crises can cause severe pain due to tissue ischemia from sickled cells obstructing blood flow. When using the urgent vs. non-urgent approach to client care, the nurse should identify that addressing the child's pain is the priority after addressing the child's hypoxia. A nurse is caring for a school-age child following an appendectomy. After reviewing the information in the child's medical record, which of the following findings should the nurse identify as a potential complication? Select the 3 findings from the child's medical record that the nurse should identify as indications of a potential complication. Vital Signs Day of admission: Temperature 37.1° C (98.8° F) Heart rate 100/min Respiratory rate 20/minBlood pressure 94/60 mm Hg Oxygen saturation 97% WBC count is correct. The child's WBC count has increased significantly following the procedure. The nurse should identify that this is a potential indication of a postoperative infection. Abdomen assessment is correct. The child's abdomen is rigid and distended and they are reporting increased pain. The nurse should identify that this is a potential indication of a postoperative infection. Temperature is correct. One day following surgery, the child's temperature has increased and is above the expected reference range. The nurse should identify that this is a potential indication of a postoperative infection. A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? Poor personal hygiene Rationale: A toddler's poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision. A nurse is caring for a preschooler who was recently admitted to a pediatric unit. The nurse is reviewing the information in the child's electronic medical record (EMR). For each EMR finding, click to specify if the finding is consistent with nephrotic syndrome, acute poststreptococcal glomerulonephritis, or hemolytic uremic syndrome. Each finding may support more than one disease process. Nurses' Notes The preschooler's guardians report that their child had a gastrointestinal illness with some Temperature is consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome. According to the EMR, the child's temperature is outside the expected reference range and is increasing. The child who has acute poststreptococcal glomerulonephritis may present with a low-grade fever. The child who has hemolytic uremic syndrome may experience fever that is high enough to cause hallucinations and lethargy. BUN level is consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome. According to the EMR, the child's BUN level is elevated, which indicates an impairment of kidney function. With acute poststreptococcal glomerulonephritis, a streptococcal infection invades the inner membranes of the kidney, which affects filtration and blood flow. With hemolytic uremic syndrome, intravascular coagulation occurs in the endothelium of the glomeruli of the kidneys, which impairs filtration and blood flow. Platelet count is consistent with hemolytic A nurse on a pediatric unit is caring for a toddler. Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the toddler. Medical History Hemophilia A Nurses' Notes 1100: Guardian reports that the toddler fell at home while playing with toys. Since the fall, the toddler has been very irritable, crying uncon Administer factor VIII is anticipated. Rationale: The child is experiencing an acute episode of hemophilia due to a recent fall. During this acute episode, there is potential for internal bleeding into the joint spaces. Therefore, administering factor VIII is anticipated to control bleeding. Apply ice packs to the affected joints is anticipated. Rationale: The child is experiencing an acute episode of hemarthrosis due to a recent fall, as evidenced by the bruising and swelling of the knee joint. Therefore, applying ice packs to the affected joints is anticipated to manage discomfort and decrease bleeding into the joint. Administer morphine PRN pain is anticipated. Rationale: The child is experiencing severe pain. Opioids can be administered in the inpatient setting to relieve pain. Otherwise, acetaminophen can be given at home for pain. Aspirin and NSAIDs should be avoided because they inhibit platelet function and might increase bleeding. Perform passive range-of-motion (ROM) ex A nurse is caring for an 8-month-old infant. Upon evaluation of the infant's status at 0630, the nurse should identify which of the following as signs of improvement? Nurses' Notes Day of admission 0515: Infant is admitted for moderate acute laryngotracheobronchitis (LTB) and decreased fluid intake. The infant's parent reports it has been more than 12 hr since the infant last voided. The infant is restless, irritable, has a hoarse cry, and is not easily consoled by the parent. Audible inspirato Infant is sleeping in parent's arms is correct. Restlessness and irritability are potential indications of hypoxia and impending airway obstruction. The infant was restless and irritable on admission, even when the parent was holding them. Therefore, this finding is an indication that the infant's condition has improved. SpO2 is 96% with 100% cool mist oxygen via blow-by is correct. A low SpO2 is an indication of hypoxia. The infant's SpO2 has increased from 89% to 96%, which is within the expected reference range. Therefore, this finding is an indication that the infant's condition has improved. Breath sounds are present and equal bilaterally in the bases is correct. This finding indicates increased air movement compared to the 0600 assessment. Therefore, this finding is an indication that the infant's condition has improved. Infant voided 34 mL is correct. The infant's parent reported upon admission that the infant had not voided in over 12 hr. The infant's mucous membranes were n A nurse is caring for a 15-year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? Mental confusion Rationale: A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an over secretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur. A nurse is providing discharge teaching to the parents of a 3-month-old infant following a cheiloplasty. Which of the following instructions should the nurse include? "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days." Rationale: The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.