NCLEX-RN · Question #687
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
The correct answer is D. Temperature rose to 102_F rectally. (A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is…
Question
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
Options
- AEvidence of perineal irritation
- BPulse fell from 102 to 96
- CPulse increased from 96 to 102
- DTemperature rose to 102_F rectally
How the community answered
(49 responses)- A18% (9)
- B4% (2)
- C6% (3)
- D71% (35)
Explanation
(A) Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. (B) This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. (C) This rise in pulse rate is probably not significant, but it is important tomonitor for continued (D) This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
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