Author Question: While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a ... (Read 104 times)

anjilletteb · **on:** Jun 28, 2018

While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system would the nurse suspect as having an ongoing disease process?

1. Genitourinary
2. Cardiac
3. Gastrointestinal
4. Respiratory

Question 2

While inspecting a five-year-old child's ears with an otoscope, the nurse notes that the right membrane is red and there is an absence of light reflex. In view of these findings, which vital sign parameter would most concern the nurse?

1. Heart rate
2. Temperature
3. Blood pressure
4. Respirations

Ksanderson1296 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

3
Rationale 1: Tenting of the skin and dry mucous membranes could be signs of dehydration, and edema could be a sign of fluid overload. Both of these conditions could be secondary to problems with functioning of the genitourinary system.
Rationale 2: Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.
Rationale 3: This infant's sclerae are showing signs of jaundice, which most likely is secondary to a failure or malfunction of the liver in the gastrointestinal system.
Rationale 4: Cyanosis of the skin and mucous membranes is generally a sign of problems with the cardiac and/or respiratory system.
Global Rationale:

Answer to Question 2

2
Rationale 1: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.
Rationale 2: The red finding indicates that there is probably infection in the middle ear while the absence of life reflex indicates a bulging tympanic member, which is also associated with infection.
Rationale 3: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.
Rationale 4: Although there could be changes in heart rate, respiratory rate, and blood pressure, these are not indicators specific to the presence of infection.
Global Rationale: