A nurse is participating in the care of an 8-year-old child on an inpatient pediatric unit. Click to highlight the findings that indicate the client requires immediate follow-up. To deselect a finding, click on the finding again. Categories Findings Integumentary Skin feels cool to the touch Capillary refill 3 seconds Dressing on right hand shows small amount of moisture through gauze. Vital Signs Blood pressure 102/50 mm Hg Temperature 35.8° C (96,4° F) Respiratory rate 20/min Genitourinary Output 25 mL Sensory Child is drowsy

Rationale for correct choices: • Skin feels cool to the touch: Cool skin in a burn patient may indicate poor perfusion and early shock. Hypoperfusion can result from fluid loss due to burns, placing the child at risk for hypovolemic shock. Immediate assessment and intervention are required to restore adequate circulation. • Capillary refill 3 seconds: Delayed capillary refill suggests impaired peripheral perfusion and possible hypovolemia. In pediatric burn patients, this is a sensitive indicator of early circulatory compromise and warrants urgent follow-up. • Temperature 35.8° C (96.4° F): Hypothermia is a serious concern in burn patients due to impaired skin barrier and heat loss. Low body temperature increases metabolic demand, impairs coagulation, and can worsen hemodynamic instability, requiring immediate intervention. • Output 25 Ml: Low urine output indicates potential renal hypoperfusion and inadequate fluid resuscitation. Monitoring and maintaining adequate urinary output is critical in burn patients to assess fluid status and prevent acute kidney injury. • Child is drowsy: Altered level of consciousness may reflect hypoperfusion, hypoxia, or early shock. Changes in neurological status in burn patients are an urgent warning sign requiring immediate assessment and intervention. Rationale for incorrect choices: • Dressing on right hand shows small amount of moisture through gauze: A small amount of moisture on the dressing is expected postoperatively and does not indicate immediate compromise. It should be monitored but does not require urgent intervention. • Blood pressure 102/50 mm Hg: This blood pressure is within normal pediatric range for an 8-year-old child and does not indicate immediate concern. The priority is on perfusion, urine output, and neurological status rather than isolated BP. • Respiratory rate 20/min: Respiratory rate is within normal limits for this age group (18–25 breaths/min). No immediate intervention is needed based on this finding alone.