Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.)

Correct Answer: C

Rationale: Cool extremities and decreased skin turgor (C) are indications of poor perfusion as shock progresses. The body is shunting blood away from the peripheries to maintain perfusion to vital organs.

Correct Answer: C

Rationale: The client at risk for developing AIDS, which is caused by the Human Immunodeficiency Virus (HIV), should be advised to have an ELISA test for antibodies to check for the presence of the virus. ELISA is a standard blood test used for HIV screening because it can detect antibodies produced by the body in response to HIV infection. Early detection through testing is crucial to initiate treatment interventions and prevent further transmission of the virus. It is important for the client to undergo this test to determine their HIV status and receive appropriate medical care and support.

Correct Answer: D

Rationale: Children with acute lymphocytic leukemia commonly present with a combination of symptoms which can include fatigability, persistent fever of unknown cause, and a tendency to bruise easily. Fatigue is a common complaint in children with leukemia due to anemia caused by decreased production of healthy red blood cells. Persistent fevers can be a sign of infection, anemia, or other complications related to leukemia. Additionally, children with leukemia may have a low platelet count, leading to easy bruising or bleeding tendencies. Therefore, all of the characteristics mentioned in the options are correct for a child with acute lymphocytic leukemia.

Correct Answer: B

Rationale: Atrial septal defect (ASD) often presents with a systolic ejection murmur at the left upper sternal border and a fixed split second heart sound.

Correct Answer: A

Rationale: The t(4;11) translocation is commonly found in infantile ALL and is associated with a poor prognosis.