Case Study Question 5 of 6 A 2-year-old female is brought to the Emergency Department by her mother with a 2-day history of fever, vomiting, and diarrhea.   Nurses’ Notes   0800: 2-year-old female brought to Emergency Department by her mother. Client has a 2-day history of fever, vomiting, and diarrhea. Mother reports client has had “multiple” episodes of liquid stool per day (5 to 6 times per day), decreased oral intake, and multiple emesis. Mother states, “She can’t keep much down. She has been throwing up everything.” Client is alert but irritable. She was initially crying but making very few tears. Client weighs 12 kg (26.4 pounds). Mother reports client has a diaper rash. Mother reports changing diaper only when client has diarrhea but has not had any diapers since yesterday that were only urine.   0815: Assessment of client shows skin turgor with tenting, eyes are slightly sunken, lips are pale and dry, hyperactive bowel sounds, delayed capillary refill.   0830: Medicated with Acetaminophen. Attempting oral rehydration.     Vital Signs   Time 0815 Temp 39.3°C/102.7°F temporal HR 142 RR 38 B/P 88/52 Pulse oximeter 96%   Orders   Category Orders Nursing Oral rehydration with standard oral rehydration solution: 75 mL/kg over 4 hours Monitor intake and output Medications Acetaminophen 15 mg/kg PO every 6 hours PRN for fever >100.5F (38.1C) Monitoring Obtain stool culture if stool is available. Obtain vital signs every 2 hours     Question 5: The nurse receives orders. What should the nurse teach the client’s parents about the treatment plan? Select all that apply.

Case Study Question 1 of 6 A 2-year-old female is brought to the Emergency Department by her mother with a 2-day history of fever, vomiting, and diarrhea.   Nurses’ Notes   0800: 2-year-old female brought to Emergency Department by her mother. Client has a 2-day history of fever, vomiting, and diarrhea. Mother reports client has had “multiple” episodes of liquid stool per day (5 to 6 times per day), decreased oral intake, and multiple emesis. Mother states, “She can’t keep much down. She has been throwing up everything.” Client is alert but irritable. She was initially crying but making very few tears. Client weighs 12 kg (26.4 pounds). Mother reports client has a diaper rash. Mother reports changing diaper only when client has diarrhea but has not had any diapers since yesterday that were only urine.     Vital Signs   Time 0815 Temp 39.3°C/102.7°F temporal HR 142 RR 38 B/P 88/52 Pulse oximeter 96%   Question 1: Select the three (3) assessment findings that require immediate follow up or evaluation. 

Which of the following would be most appropriate to include in the plan of care for a child who has undergone surgery for removal of a brain tumors?

Case Study Question 3 of 6 A 2-year-old female is brought to the Emergency Department by her mother with a 2-day history of fever, vomiting, and diarrhea.   Nurses’ Notes   0800: 2-year-old female brought to Emergency Department by her mother. Client has a 2-day history of fever, vomiting, and diarrhea. Mother reports client has had “multiple” episodes of liquid stool per day (5 to 6 times per day), decreased oral intake, and multiple emesis. Mother states, “She can’t keep much down. She has been throwing up everything.” Client is alert but irritable. She was initially crying but making very few tears. Client weighs 12 kg (26.4 pounds). Mother reports client has a diaper rash. Mother reports changing diaper only when client has diarrhea but has not had any diapers since yesterday that were only urine.   0815: Assessment of client shows skin turgor with tenting, eyes are slightly sunken, lips are pale and dry, hyperactive bowel sounds, delayed capillary refill.     Vital Signs   Time 0815 Temp 39.3°C/102.7°F temporal HR 142 RR 38 B/P 88/52 Pulse oximeter 96%   Question 3: Complete the following sentence by choosing from the list of options.   Based on the overall assessment of the client she is most likely experiencing __________ (select from: mild, moderate, or severe) dehydration as evidenced by ___________ (select from: weight, oral mucosa, or pulse oximeter).    _______ _______

A child is diagnosed with hemolytic-uremic syndrome (HUS). Review of the child’s laboratory test results would reveal which of the following?

The nurse is caring for a 5-year-old boy undergoing treatment for a neuroblastoma. Which of the following nursing diagnoses is specific to radiation therapy?

A nurse is caring for a child with suspected acute rheumatic fever. Which of the following assessment findings points to this infection?

The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which of the following responses indicates a need for further teaching?

The nurse is administering a new antibiotic as ordered. The child vomits the dose after 15 minutes. What should the nurse do next?

The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which of the following findings would be the most highly suspicious of transposition?