Item 1 of 6
Question 1 of 6
Scenario
The following scenario applies to the next 6 items. The nurse in the pediatric emergency department cares for a 10-year-old female client.
Health History
A 10-year-old female presents to the emergency department with her father, who reports she has had increased thirst and urination for the past 2 weeks, including waking up at night to use the bathroom. Over the past 3 days, she has had nausea, vomiting twice today, and abdominal pain. Her father states she has "lost weight even though she's been eating more than usual" and seems unusually tired. This morning, he noticed her breathing seemed "fast and deep" and her breath had a strange, fruity odor. She has no significant past medical history and takes no home medications. Family history is significant for type 1 diabetes mellitus in a maternal aunt. Immunizations are up to date.
Assessment — 1015
| System | Findings |
|---|---|
| Neurologic | Lethargic but arousable to voice; oriented to person only |
| HEENT | Dry mucous membranes; sunken eyes; fruity-scented breath |
| Respiratory | Deep, rapid respirations; lungs clear to auscultation bilaterally |
| Cardiovascular | S1 and S2 present; no murmur; capillary refill 3 seconds |
| Gastrointestinal | Abdomen soft, diffusely tender to palpation; bowel sounds hypoactive x4 quadrants; emesis x1 in triage |
| Integumentary | Skin warm, poor turgor with tenting noted on forearm |
| Urological | Reports frequent urination; last voided 1 hour ago, large volume |
Vital Signs — 1015
| Vital Sign | Value |
|---|---|
| Temperature | 98.9°F (37.2°C) |
| Heart Rate | 128 bpm |
| Respiratory Rate | 34/min, deep |
| Blood Pressure | 92/58 mmHg |
| Pulse Oximetry | 98% on room air |
| Weight | 61 lb (27.7 kg); father reports usual weight ~68 lb (30.8 kg) |
| Point-of-care glucose | 486 mg/dL (27.0 mmol/L) |
The nurse has reviewed the Health History, Vital Signs for 1015, and Assessment for 1015. Select the top 5 findings that require immediate follow-up.
0 of 6 items answered. Answers and rationales are revealed only after you submit the test.