A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?
"My child has some swelling around her eyelids and mouth."
"My child has a temperature of 100.7 degrees Fahrenheit."
"My child only ate 2 ounces during her last feeding."
"My child cries when I touch the area where she received the shot.".
The Correct Answer is A
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Contact precautions are indicated when the client has a condition that can be easily transmitted through direct contact with the client or their environment. Measles, which is an airborne disease, requires more stringent precautions due to its mode of transmission.
Choice B rationale:
The correct choice. Measles is spread through airborne particles, making airborne precautions necessary. These precautions include placing the client in a negative pressure room, wearing appropriate respiratory protection (e.g., N95 mask), and ensuring that healthcare providers are properly protected from inhaling infectious particles.
Choice C rationale:
A protective environment is a specialized form of isolation used for clients with compromised immune systems, such as those undergoing stem cell transplants. It involves maintaining a sterile environment to prevent the introduction of pathogens. This level of precautions is not applicable to clients with measles.
Choice D rationale:
Droplet precautions are appropriate for diseases that are transmitted through respiratory droplets generated by coughing, sneezing, or talking. Measles, however, is transmitted through smaller airborne particles that can remain suspended in the air for longer periods, making airborne precautions the most suitable choice.
Correct Answer is A
Explanation
Choice A rationale:
Lethargy, or extreme fatigue and sluggishness, is a characteristic symptom of hypothyroidism. Hypothyroidism occurs due to an underactive thyroid gland, which leads to a decrease in metabolic activity and energy levels. Children with hypothyroidism often exhibit lethargy, weakness, and a lack of interest in activities. This is due to the reduced metabolic rate and overall slowing down of bodily functions.
Choice B rationale:
Diarrhea is not a common finding associated with hypothyroidism. In fact, hypothyroidism tends to slow down gastrointestinal motility, leading to constipation rather than diarrhea. Therefore, diarrhea is not expected as a symptom in a child with hypothyroidism.
Choice C rationale:
Tachycardia, an elevated heart rate, is not typically associated with hypothyroidism. Instead, hypothyroidism often leads to bradycardia (a slower-than-normal heart rate) due to the overall slowing of the body's metabolic processes.
Choice D rationale:
Hirsutism, which refers to excessive hair growth in areas where hair growth is typically seen in males, is not a common finding in hypothyroidism. Hirsutism is more commonly associated with hormonal imbalances such as polycystic ovary syndrome (PCOS) rather than hypothyroidism.
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