The nurse is conducting an assessment on a school-age child with urosepsis. Which assessment finding should the nurse expect?

Correct Answer: A

Rationale: In a school-age child with urosepsis, the nurse should expect the assessment finding of fever with a positive blood culture. Urosepsis is a severe infection in the urinary tract that has spread to the bloodstream, causing systemic symptoms such as fever. Positive blood cultures indicate the presence of bacteria in the bloodstream, confirming the diagnosis of sepsis. Other common symptoms of urosepsis may include chills, rapid heart rate, increased respiratory rate, and altered mental status. Proteinuria and edema (choice B) are more indicative of kidney disorders such as nephrotic syndrome rather than urosepsis. Oliguria and hypertension (choice C) may be seen in conditions like acute kidney injury but are not specific to urosepsis. Anemia and thrombocytopenia (choice D) are more characteristic of conditions such as hemolytic uremic syndrome rather than urosepsis.

Correct Answer: C

Rationale: For a preschool child, the appropriate explanation about cardiac catheterization would be that the test is short, usually taking less than 1 hour. This explanation is suitable for a preschool child because it provides a simple and clear understanding of what to expect during the procedure. Preschool-aged children have limited attention spans and may become anxious about medical procedures, so providing a concise and reassuring explanation can help alleviate their fears. Additionally, knowing that the test will not take a long time can help the child feel more at ease about the procedure.

Correct Answer: B

Rationale: When preparing a school-age child and the family for heart surgery, it is essential to provide honest and age-appropriate information to help the child feel more comfortable and reduce anxiety. Letting the child hear the sounds of an ECG monitor is beneficial as it allows them to become familiar with medical equipment and procedures, making them less intimidated by the unfamiliar sounds they may encounter during and after surgery. Familiarizing the child with the sounds can also help alleviate fears and promote understanding of what is happening during the procedure. It is important to maintain open communication, address concerns, and prepare the child and family for what to expect before, during, and after surgery.

Correct Answer: C

Rationale: Toxic shock syndrome is characterized by several clinical manifestations, including a diffuse erythematous macular rash. The rash typically appears early in the course of the illness and may be followed by desquamation (peeling of the skin). Other common symptoms of toxic shock syndrome include fever, hypotension, multi-organ dysfunction, headache, myalgia, and gastrointestinal symptoms. Severe hypertension and subnormal temperature are not typically associated with toxic shock syndrome. Papular rash over extremities is not a classic manifestation of toxic shock syndrome.

Correct Answer: D

Rationale: The nurse should notify the physician stat in this situation. The presence of blood-tinged urine and painful bladder spasms in a patient with a three-way Foley catheter and continuous bladder irrigation post TURP could indicate a potential complication such as hemorrhage or clot retention. It is crucial to ensure prompt medical evaluation and intervention to address these issues effectively. Waiting or administering pain medication without further assessment could delay necessary treatment and lead to worsening of the patient's condition. Therefore, notifying the physician immediately is the most appropriate action in this scenario.