Week 6 EAQ
The nurse is teaching skin and basic care to the parent of a 6-month-old infant with eczema. Which statement indicates that the parent needs further teaching?
"I'll have to be careful not to cut my baby's nails short." The baby's nails should be cut very short to minimize injury from scratching. Wool and synthetic fabrics tend to irritate eczema. Scented products are irritating and should be eliminated for infants with eczema. Moisturizing the skin frequently is the best preventative measure infants with eczema.
The child who is human immunodeficiency virus (HIV) positive has CD4 count that shows severe immunosuppression. Which immunizations can the child be given safely at this time? Select all that apply. One, some, or all responses may be correct.
-Hepatitis A -Polio vaccine (IPV) -Diphtheria, tetanus, pertussis (DTaP)
An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse provide for the infant? Select all that apply. One, some, or all responses may be correct.
-Instilling saline nose drops -Maintaining droplet precautions -Nasal suctioning to remove mucus Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSV produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. Research has shown that bronchodilators are not effective in the treatment of bronchiolitis.
The nurse is caring for a 4-year-old child who has been hospitalized with an acute asthma exacerbation. Which assessment finding would require immediate action by the nurse?
Diminished breath sounds At the beginning of an asthma exacerbation, wheezing may be heard only with a stethoscope. As the severity of the episode increases, wheezing may become audible to the unaided ear. Children in severe respiratory distress may not demonstrate wheezing because of decreased air movement; diminished breath sounds in a child may signal an inability to move air, so this finding requires immediate action to prevent respiratory failure. The normal pulse range for a 4-year-old is 80 to 125 beats per minute; a pulse of 110 beats per minute does not require action. The normal respiratory range for a 4-year-old is 20 to 30 breaths per minute, so a respiratory rate of 24 breaths per minute does not require action. A pulse oximetry reading of 95% is acceptable. Once the child has been hospitalized with an acute asthma attack, oxygen saturation should be kept at 95% or higher.
The parents of a toddler with newly diagnosed cystic fibrosis ask the nurse what causes the problems related to this disorder. Which would the nurse consider about the primary pathologic process before responding?
Mechanical obstruction of mucus-secreting glands Mucous secretions increase in viscosity and precipitate or coagulate to form concentrations in glands and ducts, resulting in obstructions. Decreased amounts of pancreatic enzymes cause impairment in the digestion and absorption of nutrients. The eccrine (sweat) glands are not hyperactive, but there is an increased concentration of sweat electrolytes (e.g., sodium and chloride). The autonomic nervous system does not play a role in the pathologic process of cystic fibrosis. There is no alteration in the mucosal lining of the intestines.
