RN Pediatric Nursing (ATI)

Correct Answer: Initiate reverse isolation precautions for this child.

Explanation:

An absolute neutrophil count (ANC) below 500 cells/mm³ is a critical level of neutropenia, which places the child at high risk for infections due to the severely reduced immune response.The primary goal in this situation is to protect the child from exposure to pathogens that could cause infection. This is achieved through reverse isolation, which involves measures to protect the patient from external sources of infection (e.g., using clean, sterile environments, and limiting visitors and staff who may carry infections).

Why Other Options Are Wrong:

Transfer the child to a negative pressure room: A negative pressure room is typically used for patients with airborne infections (e.g., tuberculosis), not for patients who are immunocompromised due to neutropenia. The correct measure here is reverse isolation, not the use of a negative pressure room.

Notify the healthcare provider of the laboratory result: While it is important to notify the healthcare provider, the first action should focus on preventing infection, which can be done by initiating reverse isolation precautions. The healthcare provider will be notified as part of the ongoing care.

Call the lab and request a "stat" unit of platelets: A low ANC does not directly indicate a need for platelet transfusion, which is typically indicated for low platelet counts, not neutropenia. The issue here is the child's neutropenia and the risk of infection, not platelet count.

Conclusion:

The first priority is to protect the child from infection, so initiating reverse isolation precautions is the most immediate and appropriate intervention.

Correct Answer: Hypovolemic shock.

Explanation:

Hypovolemic shock is a type of shock caused by a significant loss of blood or fluids, leading to inadequate perfusion of tissues and organs. In this scenario, the low blood pressure, poor capillary refill, tachycardia, and bruising in the upper left quadrant of the abdomen are consistent with shock resulting from blood loss, possibly from internal bleeding due to trauma in the motor vehicle collision.

Key points supporting hypovolemic shock:

Falling blood pressure and tachycardia: The body compensates for decreased blood volume by increasing the heart rate in an attempt to maintain blood flow to vital organs.

Poor capillary refill: This indicates inadequate perfusion, a hallmark of shock.

Low central venous pressure: Suggests reduced circulating blood volume.

Bruising in the abdomen: Could indicate internal bleeding, particularly in areas like the spleen or liver, which can be injured in a high-impact collision.

Why Other Options Are Wrong:

Neurogenic shock:

This occurs when there is a disruption in the sympathetic nervous system, typically due to a spinal cord injury. It results in bradycardia (slow heart rate), hypotension, and warm, dry skin. The patient here is experiencing tachycardia and signs of blood loss, making neurogenic shock less likely.

Cardiogenic shock:

This type of shock is due to the heart's inability to pump blood effectively, often resulting from a heart attack or heart failure. It typically involves pulmonary edema, jugular venous distension, and low cardiac output, but the patient is showing signs of blood loss and trauma, not heart failure.

Distributive shock:

This involves abnormal distribution of blood flow, commonly seen in conditions like sepsis, anaphylaxis, or neurogenic shock. It typically presents with warm skin, hypotension, and low systemic vascular resistance, but it does not typically involve internal bleeding or trauma like in this case.

Conclusion:

The signs and symptoms described—low blood pressure, tachycardia, poor capillary refill, low central venous pressure, and abdominal bruising—point to hypovolemic shock, most likely due to internal bleeding from the trauma of the motor vehicle collision. Immediate intervention is necessary to address the blood loss and stabilize the child.

Correct Answer: Have a bulb syringe readily available to remove secretions.

Explanation:

Infants with respiratory infections are often unable to clear their airways effectively due to excessive secretions. A bulb syringe is an essential tool in this situation, as it can help suction secretions from the infant's nose and mouth. This ensures the infant maintains a clear airway, which is critical in managing respiratory distress or potential pneumonia. Ensuring the airway is clear is the top priority to prevent further complications.

Why Other Options are Wrong:

Give small, frequent feedings of fluids:

While hydration is important, especially during illness, the immediate concern for this infant is clearing the airway to ensure adequate breathing. The airway needs to be addressed first to prevent respiratory distress, and once the airway is clear, fluid intake can be managed.

Accurately chart observations regarding breath sounds:

Monitoring and documenting breath sounds are important for ongoing assessment of the infant’s condition, but this is not the immediate priority. Ensuring the infant’s airway is clear takes precedence to prevent respiratory compromise, which is a more urgent concern.

Encourage older siblings to visit:

Although emotional support can be beneficial, it should not take priority over the infant’s airway management. Additionally, visits from siblings could increase the risk of further exposure to infection if they have been in contact with other environments, making this option less appropriate in this scenario.

The correct answer is Doll's eye reflex intact

The Doll's eye reflex is a primitive reflex that should disappear by 2 months of age. This reflex occurs when the infant's head is turned to one side, but their eyes move in the opposite direction, appearing fixed. If this reflex is still present at 4 months, it suggests that the infant's neurological development is not progressing as expected. Therefore, the nurse should notify the provider.

Why the other options are normal:

Positive Babinski reflex: The Babinski reflex is present in infants up to about 12 months of age, so it is normal for a 4-month-old.

Presence of tears when crying: By 3-4 months, infants typically begin producing tears when they cry, so this is normal at this age.

No head lag when pulled to a sitting position: By 4 months, many infants have good head control and show minimal or no head lag when pulled to a sitting position, which is normal.

Summary

A Doll's eye reflex intact at 4 months is abnormal and requires notification to the provider.

Correct Answer: Believes the condition is a punishment

Preschool-age children (typically ages 3 to 5) have a very limited understanding of illness and death. Their cognitive development is still focused on egocentrism, which means they view things from their own perspective and may interpret events based on their own feelings and experiences. 

Preschool-age children may believe their illness is a punishment because they lack the cognitive ability to understand the concept of illness or death as something unrelated to their own actions. They may think that something they did (such as misbehaving) caused their condition. This reflects the child's developmental stage of magical thinking.

Why Other Options are Wrong:

“Expresses interest in the funeral arrangements”:

Preschool children do not typically have the cognitive ability to understand the concept of death in a concrete way. Interest in funeral arrangements is more typical of older children (such as school-age children) who are beginning to understand death more concretely.

“Accepts death is inevitable”:

Preschool children do not have an understanding of the inevitability of death. They often view death as reversible or temporary, and they may not understand that death is permanent. The understanding of death as inevitable is more commonly seen in older children (around age 7 or older) who have developed more abstract thinking.

“Feels excessive anxiety about physical changes”:

While preschool children may experience some anxiety, excessive anxiety about physical changes is not a typical feature of terminal illness in this age group. They may be more concerned with the immediate effects of their illness, but their understanding is often limited. Older children or adolescents are more likely to experience anxiety related to physical changes, especially if they understand the impact on their appearance.

Summary:

For preschool-age children, it is most common for them to believe their illness is a punishment due to their egocentric thinking. They are unlikely to have a full understanding of death or the future implications of their illness.

Correct Answer: Magnetic resonance imaging (MRI).

Explanation:

Magnetic resonance imaging (MRI) is the most sensitive imaging modality for detecting osteomyelitis, especially in the early stages. It provides detailed images of both bone and soft tissue and is highly effective in identifying areas of infection, inflammation, and bone marrow involvement, which are key indicators of osteomyelitis.

Why Other Options Are Wrong:

Radiography (X-ray):

X-rays are often the first imaging modality used to assess bone infections, but they are not sensitive enough to detect early osteomyelitis. X-rays may only show changes after significant bone destruction has occurred, which could delay diagnosis.

Fluoroscopy:

Fluoroscopy is a real-time X-ray used for guidance during procedures but is not typically used for diagnosing osteomyelitis or assessing bone infections. It does not provide the detailed imaging needed for detecting soft tissue involvement or early bone changes.

Computed tomography (CT):

CT scans provide good detail of bone structures but are not as sensitive as MRI in detecting early osteomyelitis or soft tissue changes related to infection. CT may be more useful in assessing complex bone fractures or abscess formation but not as optimal for soft tissue and early bone marrow involvement.

Conclusion:

MRI is the preferred imaging technique for early detection of osteomyelitis, particularly when the infection is non-responsive to antibiotics and involves soft tissue and bone marrow.

The correct answer is: Bradypnea

Bradypnea

Morphine is an opioid, and a known adverse effect of opioids is respiratory depression, including bradypnea (slow breathing). This can be life-threatening and is a priority to monitor.

Why Other Options are Incorrect

Prolonged wound healing

Morphine does not directly impair wound healing. Factors like poor nutrition, infection, or certain medical conditions affect wound healing.

Stevens-Johnson syndrome

 Stevens-Johnson syndrome is a rare adverse effect of some medications, such as certain antibiotics, antiepileptics, and NSAIDs. It is not a typical adverse effect of morphine

Hypertension

Morphine commonly causes hypotension, not hypertension, due to its vasodilatory effects.

Key Takeaway:

When administering morphine, the nurse should closely monitor for signs of respiratory depression, including bradypnea, decreased oxygen saturation, and sedation.