Chapter 37 PREPU
The physician has ordered ibuprofen 150 mg every 6 hours as needed for a 3-year-old child for a fever greater than 38°C (100.4°F). The label of the ibuprofen bottle reads "ibuprofen oral suspension 100 mg/5 ml." How much ibuprofen liquid will the nurse administer if the child's temperature goes above 38°C (100.4°F)? Record your answer using one decimal place.
7.5
The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort? Discuss with the child the importance of not scratching lesions. Administer infant aspirin every 4 hours as necessary for comfort. Apply cool compresses to the skin to stop local itching. Dress the child warmly to bring out the rash so that it fades quickly.
Apply cool compresses to the skin to stop local itching. Explanation: Rashes can be uncomfortable and irritating. Parents need to be educated on ways to relieve discomfort and to protect and maintain skin integrity. Cool compresses or cool baths will help to relieve the itching associated with the rash. Antipruritics may be necessary to help with itching. To protect the skin, the child should be instructed not to scratch the skin to alleviate itching. The child's fingernails should be kept short. Keeping the child dressed warmly will not bring out the rash any sooner. Being warm will, however, cause increased body temperature and intensify the itching. Aspirin should not be used in children as an antipyretic. There is an increased risk of developing Reye syndrome.
The nurse is caring for a child whose family recently emigrated from a developing country. While completing the admission history, the parents report all the child's immunizations are up to date. Which nursing action is most appropriate? Request parents follow WHO vaccine recommendations. Document that immunizations are up to date in the chart. Ask parents which immunizations have been given. Administer varicella and meningococcal vaccines.
Ask parents which immunizations have been given. Explanation: When caring for a child recently emigrated from a developing country, the nurse should be aware that WHO recommended vaccinations and U.S. recommended vaccinations may be different. The most appropriate action is for the nurse to determine which vaccinations have been given to decide if additional immunizations may be needed.
The nurse is performing a physical examination for a 7-year-old girl who was bitten by a tick. What would alert the nurse to the possibility of early localized Lyme disease? Cranial nerve palsies Bull's-eye rash around the bite Multiple erythema migrans on the skin Recurrent arthritis in the large joints
Bull's-eye rash around the bite Explanation: A bull's-eye rash (ring-like rash) around the bite is typical of early localized Lyme disease. Multiple erythema migrans on the skin occurs during early disseminated disease. Cranial nerve palsies are indicative of early disseminated disease. Recurrent arthritis in the large joints occurs in the late stage of the disease.
The pediatric nurse knows that there are a number of anatomic and physiologic differences between children and adults. Which statement about the immune systems of infants and young children is true? Cellular immunity is not functional in children. Children have an immature immune response. Passive immunity overlaps immunizations. Children have an increased inflammatory response.
Children have an immature immune response. Explanation: Infants and young children are more susceptible to infection due to the immature responses of their immune systems. Cellular immunity is generally functional at birth; humoral immunity develops after the child is born. Newborns have a decreased inflammatory response. Young infants lose the passive immunity from their mothers, but disease protection from immunizations is not complete.
The mother of a 10-year-old child diagnosed with rubella asks what can be done to help her child feel better during her illness. What information can be provided? Antiviral medications can be prescribed. Antibiotic therapy may be initiated. Encourage rest and relaxation. Range of motion to prevent contractures.
Encourage rest and relaxation. Explanation: Rubella infection is usually mild and self-limited. The care given is normally supportive. Rest is encouraged. Medications administered are normally limited to antipyretics and analgesics. Antibiotic and antiviral therapies are not normally included in the plan of treatment. Range of motion is not needed as mobility of the client is not limited.
What is the leading cause of neonatal sepsis and death? Epstein-Barr virus infection cytomegalovirus infection Group B streptococcus Neisseria meningitidis
Group B streptococcus Explanation: Sepsis is a systemic overresponse to infection. It is very serious and can produce septic shock and death. In infants under the 3 months of age the most causative agents are group B streptococcus, Escherichia coli, Staphylococcus aureus, enteroviruses, and the herpes simplex virus. Any time a febrile, ill-appearing neonate is seen, a full septic work-up is done. Neonates have the poorest outcomes from sepsis. Neisseria meningitidis is one cause of sepsis in older children. The Epstein-Barr virus is a herpes virus that causes mononucleosis. The cytomegalovirus is a common herpes virus. It is spread through bodily fluids and is not necessarily a concern unless the person is immunocompromised or is pregnant.
Nursing students are learning about the infectious process. They correctly identify the first stage of an infectious disease to be which period? Incubation period Prodromal period Illness period Convalescent period
Incubation period Explanation: Infection occurs when an organism invades the body and multiplies, causing damage to the tissue and cells. The infectious process goes through four stages. The incubation period is the first stage of the infectious disease. It is the time between the invasion of an organism and the onset of symptoms of infection. The prodromal period is the time from the onset of nonspecific symptoms to specific symptoms, for example, cold/flu-like symptoms before Koplik spots occur in measles. The illness is the time during which symptoms of the specific illness occur. The convalescent stage is the time when the acute symptoms disappear.
A child is brought to the clinic with fever, cough, and coryza. The nurse inspects the child's mouth and observes what look like tiny grains of white sand with red rings. How would the nurse document these findings? Lymphadenopathy Nits Slapped cheek appearance Koplik spots
Koplik spots Explanation: Koplik spots are bright red spots with blue-white centers appearing primarily on the buccal mucosa and indicate rubeola (measles). They are often described as tiny grains of white sand surrounded by red rings. Lymphadenopathy is used to document enlargement of the lymph nodes. Slapped cheek appearance refers to the erythematous flushing associated with fifth disease. Nits refer to the adult eggs of pediculosis.
A nurse is preparing a presentation for parents about common childhood infectious diseases. What conditions would the nurse include as being caused by a tick bite? Select all that apply. Rocky Mountain spotted fever Ascariasis Lyme disease Scabies Psittacosis
Lyme disease Rocky Mountain spotted fever Infectious diseases caused by tick bites include Lyme disease and Rocky Mountain spotted fever. Psittacosis is transmitted to children by birds. Ascariasis is a roundworm infection. Scabies is a parasitic infection caused by a female mite.
The student nurse is discussing the plan of care for a child admitted to the hospital for treatment of an infection. Which action should be taken first? Initiate antibiotic therapy. Obtain blood cultures. Obtain urine specimen for analysis. Initiate intravenous therapy.
Obtain blood cultures. Explanation: When treating a child suspected of having an infection, the blood cultures must be obtained first. The administration of antibiotics may impact the culture's results. A urine specimen may be obtained but is not the priority action. Intravenous fluids will likely be included in the plan of care but are not the priority action.
The nurse at an outpatient facility is obtaining a blood specimen from a 9-year-old girl. Which technique would most likely be used? Administering sucrose prior to beginning. Accessing an indwelling venous access device. Using an automatic lancet device on the heel. Puncturing a vein on the dorsal side of the hand.
Puncturing a vein on the dorsal side of the hand. Explanation: The usual sites for obtaining blood specimens are veins on the dorsal side of the hand or the antecubital fossa. Administration of sucrose prior to beginning helps control pain for young infants. Accessing an indwelling venous access device may be appropriate if the child is in an acute care setting. An automatic lancet device is used for capillary puncture of an infant's heel.
A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat for a couple of days and now his temperature is over 102°F (38.9°C). He has this rash on his face and chest that looks like sunburn but feels really rough." What would the nurse suspect? Pertussis Diphtheria Scarlet fever Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA)
Scarlet fever Explanation: Scarlet fever typically is associated with a sore throat, fever greater than 101° F (38.9° C), and the characteristic rash on the face, trunk, and extremities that looks like sunburn but feels like sandpaper. CAMRSA is typically manifested by skin and tissue infections. Diphtheria is characterized by a sore throat and difficulty swallowing but fever is usually below 102°F (38.9°C). Airway obstruction is apparent. Pertussis is characterized by cough and cold symptoms that progress to paroxysmal coughing spells along with copious secretions.
A nurse is assessing a child with a tick-borne disease. What finding would indicate to the nurse that the child has developed ehrlichiosis and not Rocky Mountain spotted fever? fever malaise headache absence of rash
absence of rash Explanation: Both Rocky Mountain spotted fever and ehrlichiosis are manifested by fever, headache, and malaise. However, there is rarely a rash with ehrlichiosis, which helps to differentiate it from Rocky Mountain spotted fever.
Which child will the nurse identify as at greatest risk for developing a urinary tract infection? a 2-year-old male with otitis media a 6-month-old breastfed female an 8-month-old bottle-fed female with HIV a 1-year-old formula-fed male
an 8-month-old bottle-fed female with HIV Explanation: Factors that make an individual more prone to a urinary tract infection include young age, female gender, and immunosuppression. Infants who are formula-fed are at greater risk than infants who are breastfed. To determine the child at greatest risk, the nurse should count risk factors and determine which child has the most risk factors.
A 3-week-old infant is diagnosed with pertussis. Which antimicrobial agent would the nurse expect the physician to prescribe? azithromycin clarithromycin erythromycin trimethoprim-sulfamethoxazole
azithromycin Explanation: The macrolides (erythromycin, azithromycin, and clarithromycin) are the drugs of choice for pertussis in children older than 6 months of age. Azithromycin and clarithromycin are not FDA approved for use in infants younger than 6 months; however, infants younger than 1 month old should be treated with azithromycin because erythromycin is associated with increased risk of infantile hypertrophic pyloric stenosis. Trimethoprim-sulfamethoxazole is an alternative antibiotic for children who cannot tolerate erythromycin.
An adolescent comes to the emergency room with high fevers, chills, rigors and sweats. Malaria is suspected. When taking the health history, what question should the nurse ask first? "Is anyone else in your household sick?" "Are there days your symptoms are worse?" "When did your symptoms begin?" "Have you traveled outside North America?"
"Have you traveled outside North America?" Explanation: Malaria comes from a bite of Anopheles species of mosquito. The infection produces high fevers, chills, rigors, sweats, headaches and arthralgia. If the disease is suspected, it would be most important for the nurse to know if the adolescent had traveled to any areas in Africa, Asia or South America, where the type of mosquitoes are found that produce malaria. All of the other questions are appropriate, but they are not as important as the travel, which could help lead to a definitive diagnosis.
The nurse is assessing a child who presents with a history of fever, malaise, fatigue, and headache. The nurse notes a bulls-eye rash on the child's right leg. Which action will the nurse take? Obtain an electrocardiography (ECG). Notify the primary health care provider. Clean the rash with rubbing alcohol. Place the child on contact precautions.
Notify the primary health care provider. Explanation: The nurse would suspect the child has Lyme disease and notify the health care provider for additional testing and potential antibiotic therapy. Precautions are not indicated for clients with Lyme disease. An ECG would only be needed if cardiac symptoms were noted. It is recommended to clean the site of the tick bite with rubbing alcohol when the tick is removed, not at a later time.
A child in the clinic has a fever and reports a sore neck. Upon assessment the nurse finds a swollen parotid gland. The nurse suspects which infectious disease? Whooping cough Scabies Mumps Measles
Mumps Explanation: Mumps is an infectious disease with a primary symptom of a swollen parotid gland. It is a contagious disease spread by droplets. The child is contagious 1 to 7 days prior to the onset of the swelling and 4 to 9 days after the onset of the swelling. Pertussis is a respiratory disorder that causes severe paroxysmal coughing, which produces a whooping sound. Measles is recognized by Koplik spots in the mouth and the classic maculopapular rash that starts on the head and spreads downward. Scabies is a skin condition where lice lay eggs under the skin. The rash is very pruritic and is seen on the hands, feet, and folds of the skin.
A 6-month-old boy is brought to the doctor's office with a high fever. The physician diagnoses the child as having a viral infection of some kind and recommends acetaminophen to reduce the fever. After 3 days, the mother returns with the child. The fever is gone, but a rash of discrete, rose-pink macules approximately 2 to 3 mm and flat with the skin surface appears. Which condition should the nurse suspect? Chickenpox (varicella) Rubella (German measles) Measles (rubeola) Roseola
Roseola Explanation: Roseola begins with a high fever; after 3 or 4 days, the fever falls abruptly and a distinctive rash of discrete, rose-pink macules approximately 2 to 3 mm in size and flat with the skin surface appears. With rubella, after the 1 to 5 days of prodromal signs, a discrete pink-red maculopapular rash begins on the face, then spreads downward to the trunk and extremities. On the third day, the rash disappears. Measles feature Koplik spots (small, irregular, bright-red spots with a blue-white center point), which appear on the buccal membrane. Chickenpox is marked by a low-grade fever, malaise, and, in 24 hours, the appearance of a distinctive rash. Varicella lesions first begin as a macula, then progress rapidly within 6 to 8 hours to a papule, then a vesicle that becomes umbilicated and then forms a crust.
The nurse is discussing fever with the parents of a child who is in the emergency department with a temperature of 101°F (38.3°C). Which statement by a parent indicates an understanding of fevers and their management in the ill child? "Fevers can be beneficial because they can slow down the growth of the bacteria or virus that may be causing the infection." "We've had to wake him up in the night to give him more medicine to reduce his temperature." "My wife and I have been using cold water and washcloths on him because of the fever." "We've been giving him a little extra acetaminophen to help bring his fever down."
"Fevers can be beneficial because they can slow down the growth of the bacteria or virus that may be causing the infection." Explanation: Fevers can be protective and can help the body fight the infection. Fevers slow down bacterial or viral growth. Mismanaging fevers include inappropriate dosing of antipyretics, awakening a child at night to administer antipyretics, and using cold water or sponging the child with alcohol to reduce the temperature.
A young client arrives at the clinic with a rash on the trunk and flexor surfaces of the extremities. The parent informs the nurse that the rash started a day before on the exterior surfaces of the extremities; 2 days before, the child had a really bad rash on the face. The health care provider diagnoses the child with erythema infectiosum. The nurse tells the parent that this is also known as: enterovirus. pityriasis rosea. rosacea. fifth disease.
fifth disease. Explanation: Erythema infectiosum is also known as "fifth disease." It starts with a fever, headache, and malaise. One week later, a rash appears on the face. A day later, the rash appears on the extensor surfaces of the extremities. One more day later, the rash appears on the trunk and flexor surfaces of the extremities. Pityriasis rosea is a skin rash that begins with a large spot on the chest, abdomen, or back that is followed by a pattern of small lesions. It is self-limiting and can be treated with steroid creams. Rosacea is a chronic inflammatory skin condition that causes redness to the face. An enterovirus infection can many times cause the same symptoms as the common cold or it can include the respiratory system. It is contagious.
A school-aged child is recovering from varicella. The parent calls the school nurse and states, "my child is feeling much better" and asks when the child can return to school. What information does the nurse provide the parent? "Your child may return to school when there has been no fever for 48 hours." "Your child may return to school when a health care provider has given written permission." "Your child may return to school when all of the lesions have crusted over." "Your child may return to school when free of any lesions."
"Your child may return to school when all of the lesions have crusted over." Explanation: Varicella is a highly communicable disease. It is spread via airborne transmission or by direct contact with the nasopharyngeal secretions of an infected person. Varicella is communicable from 1 to 2 days before the rash occurs until all the vesicles have crusted over. The nurse would be correct in telling the parent the child cannot return to school, even though the child is feeling better, until all the vesicles have crusted over. The child does not have to be free of lesions. Being free of fever does not make the child less communicable. The child would not need a permission slip from the health care provider unless this is a specific requirement by the child's school district.
Parents bring their 9-year-old child to the clinic for a well-child visit. They are concerned because several children in the neighborhood have developed Lyme disease and ask for suggestions on what to do to reduce their child's risk. What would be appropriate for the nurse to suggest? Select all that apply. Contacting the health care provider if there is any area of inflammation that might be a bite. Removing ticks by rubbing them away from the skin with a credit card. Wearing protective clothing when playing in wooded areas. Dressing the child in dark clothing when going outdoors. Inspecting the skin closely for ticks after the child plays in wooded areas.
-Wearing protective clothing when playing in wooded areas. -Inspecting the skin closely for ticks after the child plays in wooded areas. -Contacting the health care provider if there is any area of inflammation that might be a bite. The nurse should teach the parents to have the child wear protective clothing and dress the child in light clothing when playing in wooded areas or going outdoors. The parents should inspect the child's skin closely for ticks after being outside in wooded areas and if any ticks are found, remove them with a tweezer, not rub them with a credit card. The parents also should be instructed to contact their health care provider if they notice any area of inflammation that might be a tick bite.
What information should be included in the teaching plan for a child with varicella? Administer aspirin for fever. Utilize salt solutions to assist in healing oral lesions. Place the child in a warm bath for skin discomfort. Remind the child not to scratch the lesions.
Remind the child not to scratch the lesions. Explanation: Varicella lesions appear first on the scalp. They spread to the face, the trunk, and to the extremities. There may be various stages of the lesions present at any one time. The lesions are intensely pruritic. The teaching plan for varicella should include that the child not scratch the lesions. Opening the lesions gives access for secondary infection to occur and causes scarring. Acetaminophen, not aspirin, should be administered for fever due to the link with Reye syndrome. The best treatment for skin discomfort is a cool bath with soothing colloidal oatmeal every 3 to 4 hours for the first few days. Warm baths cause more itching and dry the skin.
The rash in roseola is pruritic. Which measure would you teach the parent to provide comfort? Administer infant aspirin every 4 hours as necessary for comfort. Apply cool compresses to the skin to stop local itching. Discuss with the child the importance of not scratching lesions. Dress the child warmly to bring out the rash so that it fades quickly.
Apply cool compresses to the skin to stop local itching. Explanation: Rashes can be uncomfortable and irritating. Parents need to be educated on ways to relieve discomfort and to protect and maintain skin integrity. Cool compresses or cool baths will help to relieve the itching associated with the rash. Antipruritics may be necessary to help with itching. To protect the skin, the child should be instructed not to scratch the skin to alleviate itching. The child's fingernails should be kept short. Keeping the child dressed warmly will not bring out the rash any sooner. Being warm will, however, cause increased body temperature and intensify the itching. Aspirin should not be used in children as an antipyretic. There is an increased risk of developing Reye syndrome.
The mother of a child with pediculosis capitis infestation tells the nurse that she does not understand why her child still has the infestation. The mother states, "I used the prescribed treatment just like I was instructed." How should the nurse respond? "Have you been combing the hair for nits from the hair on a weekly basis?" "Do you wash your child's hair daily? Having clean hair will help get rid of the infestation." "Maybe you should use some of the home remedies like petroleum jelly or mayonnaise." "After finding the infestation did you wash items that your child's head came into contact with, like bed linen?"
"After finding the infestation did you wash items that your child's head came into contact with, like bed linen?" Explanation: To help avoid reinfestation, disinfect clothing, headgear, pillowcases, towels, and other items used by the individual within a couple of days of noticing the infestation. Washing the hair does not rid the hair of the infestation. It is suggested that home remedies are not effective. The hair should be checked and combed free of nits and lice every 2 to 3 days to prevent reinfestation.
When providing care for a child with herpes zoster (shingles), the parents ask the nurse how the child contracted this infectious disorder. Which response by the nurse is most appropriate? "Children who are immunocompromised are more likely to contract shingles." "Handwashing is an effective way to prevent the spread of infectious disorders." "Herpes zoster is a reactivation of a previous varicella zoster infection." "Your child must have been exposed to someone with herpes zoster."
"Herpes zoster is a reactivation of a previous varicella zoster infection." Explanation: Herpes zoster (shingles) is reactivation of the latent varicella zoster (chickenpox) infection that occurs during times of immunosuppression and aging. Although it is possible to contract the varicella zoster virus from a person with herpes zoster or varicella zoster, a child diagnosed with herpes zoster has already been exposed to varicella zoster. Handwashing will not directly prevent herpes zoster.
The nurse is providing teaching to the parents of a child with varicella. Which statement indicates that the parents have understood the instructions? "If he has a fever, we can give him some aspirin." "We need to make sure that he washes his hands frequently." "We should apply alcohol to the lesions every four hours." "The lesions should eventually form soft crusts that drain."
"We need to make sure that he washes his hands frequently." Explanation: The child with varicella needs to wash his hands frequently with antibacterial soap to reduce bacterial colonization. A cool bath with soothing colloidal oatmeal may help the skin discomfort. Alcohol would be too drying to the skin. Acetaminophen, not aspirin, should be used to reduce fever. The lesions should eventually crust over. Soft crusts with drainage may suggest an infection.
A child has been diagnosed with hookworm. The nurse is teaching the parent about the treatment for the condition. Which statement made by the parent confirms that further education is needed? "The medications should be taken for 2 weeks." "I should have my other children tested." "My child can play outside bare footed when treatment is done." "I should have my child eat more foods with iron."
"My child can play outside bare footed when treatment is done." Explanation: Hookworms are found in soil, especially in areas with warmer climates. They enter the body through the skin, pores and hair follicles. The treatment is with the drug albendazole. The duration is from 7 to 14 days of treatment. Most importantly, besides medication, good handwashing and sanitation practices are needed. Children should wear shoes and not go barefoot outside since the worms can enter through the soles of the feet. The worms attach themselves to the walls of the small intestine where they feed and reproduce. This can cause anemia. The child's diet should include foods high in iron or iron supplements. All children who are suspected or at high risk should be evaluated for hookworms.
The parents of a 4-month-old diagnosed with sepsis tell the nurse that the physician explained sepsis to them but they don't really understand it. The parents state, "Could you please explain it to us?" What is the best response by the nurse? "The infection your child has causes the release of toxins into the system, which can lead to impaired function in the lungs, liver, and kidneys." "Sepsis results in systemic inflammatory response syndrome (SIRS) due to infection." "The pathophysiology of sepsis is complex." "The pathogens cause an overproduction of proinflammatory cytokines. These cytokines are responsible for the clinically observable effects of the sepsis."
"The infection your child has causes the release of toxins into the system, which can lead to impaired function in the lungs, liver, and kidneys." Explanation: Keeping the answer to what sepsis is will help the parents understand the pathophysiology. While all answers are correct, the response: "The infection your child has causes the release of toxins into the system, which can lead to impaired function in the lungs, liver, and kidneys" provides the most understandable explanation and addresses the parent's question.
The nurse is providing teaching to the parents of a child with varicella. Which statement indicates that the parents have understood the instructions? "We need to make sure that he washes his hands frequently." "If he has a fever, we can give him some aspirin." "We should apply alcohol to the lesions every four hours." "The lesions should eventually form soft crusts that drain."
"We need to make sure that he washes his hands frequently." Explanation: The child with varicella needs to wash his hands frequently with antibacterial soap to reduce bacterial colonization. A cool bath with soothing colloidal oatmeal may help the skin discomfort. Alcohol would be too drying to the skin. Acetaminophen, not aspirin, should be used to reduce fever. The lesions should eventually crust over. Soft crusts with drainage may suggest an infection.
A nursing instructor is teaching the students about the standard and transmission-based precautions. What type of precautions require placing a client in an isolated room with limited access, wearing gloves during contact with the client and all body fluids or contaminated items, wearing two layers of protective clothing, and avoiding sharing equipment between clients? Airborne precautions Standard precautions Droplet precautions Contact precautions
Contact precautions Explanation: Contact precautions means placing the client in an isolation room with limited access, wearing gloves during contact with the client and all body fluids, wearing two layers of protective clothing, limiting movement of the client from the room, and avoiding sharing equipment between clients. Standard precautions are used with every client. They involve good handwashing and the use of gloves for client contact. Airborne precautions are used for diseases where small particles are dispersed in the air. They require that the client be in a negative-pressure room and, in addition to standard personal protective equipment, the mask should be N95 or higher. Varicella would need airborne precautions. Droplet precautions are used for diseases such as pertussis, which produce large droplets. They require standard precautions plus a surgical mask, preferably with a face shield.
A child in the clinic has a fever and reports a sore neck. Upon assessment the nurse finds a swollen parotid gland. The nurse suspects which infectious disease? Measles Mumps Scabies Whooping cough
Mumps Explanation: Mumps is an infectious disease with a primary symptom of a swollen parotid gland. It is a contagious disease spread by droplets. The child is contagious 1 to 7 days prior to the onset of the swelling and 4 to 9 days after the onset of the swelling. Pertussis is a respiratory disorder that causes severe paroxysmal coughing, which produces a whooping sound. Measles is recognized by Koplik spots in the mouth and the classic maculopapular rash that starts on the head and spreads downward. Scabies is a skin condition where lice lay eggs under the skin. The rash is very pruritic and is seen on the hands, feet, and folds of the skin.
A child is brought to the emergency department by his parents. The parents report that he stepped on a rusty nail about a week and a half ago. The child is complaining of cramping in his jaw and some difficulty swallowing. The nurse suspects tetanus. When assessing the child, the nurse would be alert to which muscle groups being affected next? Neck Legs Arms Stomach
Neck Explanation: Tetanus progresses in a descending fashion to other muscle groups, causing spasms of the neck, arms, legs, and stomach.
A young girl arrives at the emergency room after being bitten by a neighbor's dog. The mother is concerned her daughter will get rabies. The nurse carefully examines and treats the bite and questions the mother and daughter about the details surrounding the dog biting her. What information would most strongly indicate a risk for rabies infection in this client? The dog belonged to a neighbor The dog was properly immunized for rabies The dog was unprovoked when he bit the girl There have been no other reported instances in the area
The dog was unprovoked when he bit the girl Explanation: An unprovoked attack is much more suggestive that the animal is rabid, rather than if the bite happens during a provoked attack. The dog being immunized for rabies and there being no other reported instances of rabies in the area would indicate a lower risk that the dog was rabid. The fact that the dog belonged to a neighbor does not necessarily indicate a lower risk for rabies infection.
What is a true statement regarding measles? Peak outbreaks are in the summer. It is not contagious. The incubation period is 10 to 12 days. It is transmitted by the fecal-oral route.
The incubation period is 10 to 12 days. Explanation: Measles is a highly contagious disease spread via droplets from the nasopharyngeal secretions. The typical incubation period is 10 to 12 days. Outbreaks peak in the winter and spring. It is communicable 1 to 2 days before the onset of symptoms. The initial symptoms are fever, cough, coryza and conjunctivitis. These symptoms are followed by Koplik spots seen in the mouth. A rash develops on the head and spreads downward and outward.
The nurse is caring for multiple clients on the pediatric unit. Which child will the nurse see first? a child diagnosed with chicken pox reporting nausea and malaise a child with herpes simplex who is reporting mouth pain and pruritis a child with erythema infectiosum experiencing fatigue and confusion a child diagnosed with measles experiencing photophobia and coryza
a child with erythema infectiosum experiencing fatigue and confusion A child with erythema infectiosum experiencing fatigue and confusion is showing signs of decreased oxygenation, possibly related to aplasia of erythrocytes caused by the virus. A child with signs and symptoms of decreased oxygenation should be seen first. Nausea and malaise are symptoms of chicken pox. A child with herpes simplex will most likely report pain an pruritis. Signs and symptoms of measles include photophobia and coryza.
A child is diagnosed with scarlet fever. History reveals that the child has no known drug allergies. When preparing the child's plan of care, the nurse would anticipate administering which agent as the drug of choice? erythromycin clarithromycin penicillin V trimethoprim-sulfamethoxazole
penicillin V Explanation: Penicillin V is the antibiotic of choice. In those sensitive to penicillin, erythromycin may be used. Trimethoprim-sulfamethoxazole and clarithromycin are not used.
The nurse is attempting to control the infectious process while caring for a client. The nurse changes the client's wound dressing when the dressing becomes soiled. Which link of the chain of infection is the nurse interrupting with this intervention? portal of exit susceptible host mode of transmission reservoir
reservoir Explanation: The reservoir is the place where a microorganism grows and reproduces. Dressings left unchanged leave a dark, warm, moist environment for microorganisms to thrive. Covering the mouth and using personal protective equipment are ways to control portals of exit. Modes of transmission can be controlled with handwashing and personal protective equipment. The susceptible host is the person who is susceptible to developing an infection. Promotion of natural defenses is a good way to prevent infection.
A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of: osteomyelitis. scarlet fever. pneumonia. impetigo.
scarlet fever. Explanation: Group A streptococcal pharyngitis can progress to scarlet fever with the rash appearing in about 12 hours after the onset of the disease. Group A streptococcal pharyngitis is not associated with pneumonia. Impetigo is a group A strep infection involving the skin. Osteomyelitis can occur with an infection by group B streptococcus.
