Difficulty: Medium
Average Score: 70%
Simulated
Passage / Scenario
Vital Signs Day 1: Temperature 38.8° C (101.8° F), Heart rate 110/min, Respiratory rate 18/min, Blood pressure 110/70 mm Hg; Day 2: Temperature 37.6° C (99.7° F), Heart rate 100/min, Respiratory rate 18/min, Blood pressure 108/68 mm Hg; Laboratory Results Day 1: Hgb 15 g/dL (10 to 15.5 g/dL), Hct 40% (32% to 44%), WBC count 14,000/mm3 (5,000 to 10,000/mm3), Wound culture pending (Negative); Day 2: WBC count 15,000/mm3 (5,000 to 10,000/mm3); A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.The nurse is assessing the adolescent 24 hr after the initial visit. How should the nurse interpret the findings? For each finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition:
Correct answer
A: Improvement, B: Worsening, C: Improvement, D: Worsening
Rationale
To interpret the findings 24 hours after the initial visit for an adolescent, the nurse should consider the following:
A. Temperature: A decrease or normalization in temperature indicates improvement as it suggests resolution of infection. An increase in temperature could indicate a worsening condition due to possible infection progression.
B. WBC count: An increasing WBC count suggests a worsening condition, potentially indicating an ongoing or worsening infection. A decreasing WBC count could indicate improvement as the body is fighting off the infection.
C. Weight-bearing ability on the affected leg: Improving weight-bearing ability indicates progress in healing and recovery. Decreased weight-bearing ability could signal a worsening condition such as a fracture complication or increased pain.
D. Wound assessment: Deterioration in wound appearance, increased drainage, or signs of infection indicate a worsening condition. Healing of the wound, reduced drainage, and absence of infection signs suggest improvement.
Therefore, the correct interpretation is A: Improvement , B: W
A. Temperature: A decrease or normalization in temperature indicates improvement as it suggests resolution of infection. An increase in temperature could indicate a worsening condition due to possible infection progression.
B. WBC count: An increasing WBC count suggests a worsening condition, potentially indicating an ongoing or worsening infection. A decreasing WBC count could indicate improvement as the body is fighting off the infection.
C. Weight-bearing ability on the affected leg: Improving weight-bearing ability indicates progress in healing and recovery. Decreased weight-bearing ability could signal a worsening condition such as a fracture complication or increased pain.
D. Wound assessment: Deterioration in wound appearance, increased drainage, or signs of infection indicate a worsening condition. Healing of the wound, reduced drainage, and absence of infection signs suggest improvement.
Therefore, the correct interpretation is A: Improvement , B: W