A three-year-old child is lying in a fetal position. The child ...

[karlynnae]

A three-year-old child is lying in a fetal position. The child has pale skin, glassy eyes, and a flat affect. The child is irritable and refuses food and fluids. The child's vital signs are temperature 40.1C (104.
 
  2F), pulse 120/minute, respirations 28/minute. The best, most comprehensive description of this child's condition is: 1. Tired.
  2. Feverish.
  3. Flushed.
  4. Toxic.

Question 2

The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis?
 
  1. Impaired gas exchange
  2. Infection, risk for
  3. Anxiety (parental)
  4. Acute pain

[kardosa007]

Answer to Question 1

4
Rationale 1: The child might be tired, but this is not the best, most comprehensive description of the child's condition.
Rationale 2: The child has a high fever, but this is not the best, most comprehensive description of the child's condition.
Rationale 3: The term flushed is incorrect because it indicates a reddish appearance to the skin. The child has pale skin, which would be a white appearance to the skin.
Rationale 4: The child with a toxic appearance is described as one with a high temperature, lethargy, irritability, poor skin perfusion, hypoventilation or hyperventilation, and cyanosis.
Global Rationale:

Answer to Question 2

1
Rationale 1: Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange.
Rationale 2: The child already has an infection.
Rationale 3: The parents will be anxious about the outcome for their child, but this is not the priority diagnosis.
Rationale 4: Pain management is important but not the priority.
Global

[karlynnae]

TYSM

[chereeb]

Excellent