Question

A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.

Answer 1

Correct Answers

Temperature [ Indication of potential improvement ]
WBC count [ Indication of potential worsening condition ]
Weight-bearing ability on the affected leg [ Indication of potential worsening condition ]
Wound assessment [ Indication of potential worsening condition ]

Rationale :

🔵 1. Temperature

📌Day 1: 38.8°C (101.8°F)

📌Day 2: 37.6°C (99.7°F)

✔️ Indication of potential improvement

🌡️ A decrease in temperature suggests that the body is responding to treatment (e.g., antibiotics), and the inflammatory response is subsiding.

🌡️ Fever is a common early sign of cellulitis, and its resolution within 24 hours indicates effective infection control.

🌡️ Continual monitoring is still needed, but this downward trend is a positive clinical sign.

🔴 2. WBC Count

📌Day 1: 14,000/mm³

📌Day 2: 15,000/mm³

✔️ Indication of potential worsening condition

🦠 An increasing WBC count suggests a persisting or worsening inflammatory response or infection.

🦠 In cellulitis, WBC elevation is expected early on, but a continued rise after 24 hours may indicate inadequate response to treatment, need for antibiotic adjustment, or development of complications (e.g., abscess formation).

🦠 This finding warrants further evaluation and possibly repeating blood work or imaging.

🔴 3. Weight-bearing ability on the affected leg

📌Unable to bear weight or worsening pain

✔️ Indication of potential worsening condition

🦵 Inability or increased difficulty bearing weight on the affected leg can indicate worsening local inflammation, pain, or tissue involvement.

🦵 It may suggest expanding cellulitis, deeper soft tissue involvement, or even potential abscess formation.

🦵 Increasing pain or functional limitation is a key sign that the infection has not stabilized, despite systemic improvements like reduced fever.

🔴 4. Wound Assessment

Increased erythema, swelling, warmth, or drainage

✔️ Indication of potential worsening condition

🔍 Local wound deterioration (e.g., spreading redness, new purulent drainage, or worsening edema) is a direct sign of cellulitis progression.

🔍 Even if systemic symptoms improve, worsening at the wound site indicates that the infection remains active or localized treatment is insufficient.

🔍 This requires reassessment of wound care, antibiotic regimen, and possibly imaging to rule out abscess or deeper involvement.

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Answer 2

Correct Answers

Blank 1 Correct Option: Administer ferrous sulfate with milk to improve absorption.
Blank 2 Correct Option: Have the child brush their teeth after taking an oral dose of ferrous sulfate.
Blank 3 Correct Option: Return in 6 months for hemoglobin evaluation.

Rationale :

✅ Blank 1: Action

Correct Answer: Administer ferrous sulfate to the child between meals.

💠Iron is best absorbed in an acidic environment, and between-meal administration enhances absorption.

💠Giving iron with milk is contraindicated, as calcium in milk inhibits iron absorption.

💠Administering iron right before bedtime is not recommended, as it can cause GI upset and interfere with sleep.

💠Mild stomach upset is common; the supplement should not be discontinued unless symptoms are severe.

✅ Blank 2: Teaching Statement

Correct Answer: Have the child brush their teeth after taking an oral dose of ferrous sulfate.

💠Liquid iron supplements can stain the teeth; brushing afterward reduces this risk.

💠Iron supplements should never be chewed (especially tablets not designed for it), as this also risks staining.

💠Fluoride use is unrelated to iron absorption or staining prevention.

✅ Blank 3: Instruction

Correct Answer: Return in 1 month for hemoglobin evaluation.

💠A follow-up hemoglobin level is typically reassessed after 4 weeks (1 month) of iron therapy to evaluate response.

💠Stopping iron when symptoms improve is unsafe, as treatment typically continues for several months to restore iron stores.

💠Follow-up is necessary even if the child appears asymptomatic, as lab confirmation of recovery is essential.

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Answer 3

Correct Answers:

WBC count

Rationale :

🦠 WBC count of 16,000/mm³ is elevated (normal: 5,000–10,000/mm³) and suggests the possibility of active infection or inflammation.

🦠 In children with cystic fibrosis (CF), elevated WBCs may indicate a respiratory infection or pulmonary exacerbation, which are common and potentially serious.

🦠 Reporting this to the provider is critical to initiate or adjust antibiotic therapy, further testing, or respiratory support.

🦠 Early detection and treatment of infections in CF patients are essential to preserve lung function and prevent complications.

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Answer 4

Correct Answers:

Short stature

Rationale :

📏 Radiation therapy in young children, especially when involving the brain or spine, can damage the hypothalamic-pituitary axis, leading to growth hormone deficiency.

📏 This results in short stature or growth retardation, which is considered a late adverse effect—typically appearing months to years after treatment.

📏 The younger the child at the time of radiation, the greater the risk for impaired growth due to the vulnerability of developing tissues and endocrine regulation centers.

📏 Other late effects may include neurocognitive deficits, hormonal imbalances, and secondary malignancies, but short stature is among the most common.

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Answer 5

Correct Answers:

Heart rate 64/min

Rationale :

❤️ Digoxin slows the heart rate and increases cardiac contractility, making it effective for treating heart failure and certain arrhythmias in pediatric clients.

❤️ Before administering digoxin, it is critical to assess the child’s apical heart rate for 1 full minute.

❤️ For school-age children, the hold parameter is typically below 70 beats per minute (though protocols may vary slightly).

❤️ A heart rate of 64/min is below this threshold, indicating bradycardia, which could be worsened by digoxin, potentially leading to life-threatening arrhythmias or heart block.

❤️ Therefore, the nurse must withhold the dose and notify the provider for further instructions.

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Answer 6

Correct Answers

Gastrointestinal [ Findings ]
Integumentary [ Findings ]
Neurologic [ Findings ]

Rationale :

🫀 Cardiovascular System:

Capillary refill 4 seconds

🔴 Delayed capillary refill (>2 seconds) is a classic sign of poor perfusion and progressing dehydration.

🔴 In this context, it suggests circulatory compromise and possibly early hypovolemia or shock.

Extremities cool

🔴 Cool extremities also reflect impaired peripheral circulation, indicating the body is shunting blood to vital organs, a compensatory mechanism seen in dehydration or sepsis.

🧠 Neurologic System:

Lethargic

🔴 Lethargy in a previously alert child reflects worsening systemic status, possibly due to electrolyte imbalance, hypovolemia, or infection.

🔴 A change in mental status is always a priority assessment in pediatrics.

🧴 Integumentary:

Reports no tears

🔴 Absence of tears when crying is a red flag for moderate to severe dehydration, particularly in infants and toddlers.

🔴 This supports the pattern of ongoing fluid loss with inadequate compensation.

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Answer 7

Correct Answers:

"I will increase my food intake before I exercise."

Rationale :

🏃 Exercise increases insulin sensitivity and promotes glucose uptake into muscles, which can lower blood glucose levels.

🏃 To prevent exercise-induced hypoglycemia, adolescents with type 1 diabetes are taught to eat a carbohydrate-containing snack before physical activity, especially if insulin was recently administered.

🏃 This shows the adolescent understands how to balance insulin, food, and activity, a key self-management skill for type 1 diabetes.

🏃 Consistently applying this principle helps maintain stable glucose levels and prevent dangerous lows during sports or physical play.

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Answer 8

Correct Answers:

"I will dress my baby in lightweight clothing to sleep."

Rationale :

🛏️ Dressing an infant in lightweight clothing helps prevent overheating, which is a known risk factor for sudden unexpected infant death syndrome (SUIDS).

🛏️ Over-bundling or using thick blankets can raise the baby’s body temperature and increase the risk of sleep-related suffocation or death.

🛏️ The AAP (American Academy of Pediatrics) recommends a bare crib, placing the infant on their back to sleep, and avoiding soft bedding or bed-sharing.

🛏️ Proper thermal regulation and a safe sleep environment are key strategies to reduce the risk of SUIDS.

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Answer 9

Correct Answers:

Consolidate activities to promote the child's rest.

Rationale :

🫀 Children with heart failure have limited energy reserves due to impaired cardiac output and poor perfusion.

🫀 The nurse should group nursing care and other activities to allow for uninterrupted periods of rest, which reduces oxygen demand and cardiac workload.

🫀 Promoting rest helps minimize fatigue, conserves energy, and improves the child's overall ability to tolerate treatments and daily routines.

🫀 This intervention is essential to support tissue oxygenation and prevent further cardiac decompensation.

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Answer 10

Correct Answers:

"Wear a face mask when working within 3 feet of a child who is infected."

Rationale :

😷 Influenza is transmitted primarily through droplet spread, which includes respiratory droplets from coughing, sneezing, or talking.

😷 These droplets typically travel up to 3 to 6 feet, so wearing a surgical mask within 3 feet of an infected child helps prevent transmission.

😷 This is a standard droplet precaution and should be implemented in healthcare and school settings to protect staff and other students.

😷 Mask use, hand hygiene, and respiratory etiquette are the most effective tools in controlling the spread of influenza among school-age children.

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Options	Indication of potential improvement	Indication of potential worsening condition
Temperature
WBC count
Weight-bearing ability on the affected leg
Wound assessment

Body system	Findings
Respiratory
Cardiovascular
Gastrointestinal
Integumentary
Neurologic

QLexNursing

1 :
A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.

Correct Answers

2 :
A nurse is caring for a child.

Correct Answers

3 :
A nurse is reviewing the medical record of a school-age child who has cystic fibrosis.

Answer Options

4 :
A nurse is caring for a toddler who received radiation therapy 2 years ago for a brain tumor. Which of the following should the nurse identify as a late adverse effect of the radiation therapy?

5 :
A nurse is assessing a school-age child prior to administering digoxin. For which of the following findings should the nurse withhold the medication?

6 :
A nurse is caring for a toddler admitted to the hospital.

Correct Answers

7 :
A nurse is providing teaching to a 14-year-old adolescent who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the adolescent indicates an understanding of the teaching?

8 :
A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden unexpected infant death syndrome (SUIDS). Which of the following statements by the parents indicates an understanding of the teaching?

9 :
A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?

10 :
A nurse is planning a staff in-service about infection control measures to prevent the spread of influenza in school-age children. Which of the following instructions should the nurse include?

QLexNursing

1 : A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.

Correct Answers

2 : A nurse is caring for a child.

Correct Answers

3 : A nurse is reviewing the medical record of a school-age child who has cystic fibrosis.

Answer Options

4 : A nurse is caring for a toddler who received radiation therapy 2 years ago for a brain tumor. Which of the following should the nurse identify as a late adverse effect of the radiation therapy?

5 : A nurse is assessing a school-age child prior to administering digoxin. For which of the following findings should the nurse withhold the medication?

6 : A nurse is caring for a toddler admitted to the hospital.

Correct Answers

7 : A nurse is providing teaching to a 14-year-old adolescent who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the adolescent indicates an understanding of the teaching?

8 : A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden unexpected infant death syndrome (SUIDS). Which of the following statements by the parents indicates an understanding of the teaching?

9 : A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?

10 : A nurse is planning a staff in-service about infection control measures to prevent the spread of influenza in school-age children. Which of the following instructions should the nurse include?

1 :
A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.

2 :
A nurse is caring for a child.

3 :
A nurse is reviewing the medical record of a school-age child who has cystic fibrosis.

4 :
A nurse is caring for a toddler who received radiation therapy 2 years ago for a brain tumor. Which of the following should the nurse identify as a late adverse effect of the radiation therapy?

5 :
A nurse is assessing a school-age child prior to administering digoxin. For which of the following findings should the nurse withhold the medication?

6 :
A nurse is caring for a toddler admitted to the hospital.

7 :
A nurse is providing teaching to a 14-year-old adolescent who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the adolescent indicates an understanding of the teaching?

8 :
A nurse is providing discharge teaching to the parents of an infant who is at risk for sudden unexpected infant death syndrome (SUIDS). Which of the following statements by the parents indicates an understanding of the teaching?

9 :
A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?

10 :
A nurse is planning a staff in-service about infection control measures to prevent the spread of influenza in school-age children. Which of the following instructions should the nurse include?