A nurse is assisting in the care of a 3-year-old preschool child who has extreme manifestations of lead poisoning. Which of the following actions should the nurse perform first?
Schedule the child for a follow-up blood test to monitor lead levels over the coming weeks.
Provide supportive care to manage common symptoms of nausea and pain.
Promote a balanced diet rich in calcium and iron to help mitigate the lead absorption.
Notify the health department to investigate potential lead exposure sources.
The Correct Answer is B
A. Schedule the child for a follow-up blood test to monitor lead levels over the coming weeks. While ongoing monitoring is important, it is not the immediate priority in a child with extreme lead poisoning. Immediate intervention is needed to manage acute symptoms and prevent further complications.
B. Provide supportive care to manage common symptoms of nausea and pain. This is the correct first action. Severe lead poisoning can cause neurological and gastrointestinal symptoms, including abdominal pain, vomiting, and irritability. Supportive care addresses these symptoms while preparing for further interventions like chelation therapy.
C. Promote a balanced diet rich in calcium and iron to help mitigate lead absorption. Nutritional support is beneficial in mild to moderate cases, as calcium and iron reduce lead absorption, but it is not the first priority in extreme poisoning. Immediate medical treatment takes precedence.
D. Notify the health department to investigate potential lead exposure sources. Identifying the source of lead exposure is crucial for long-term prevention, but in cases of severe poisoning, immediate medical care is the priority before environmental interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Intussusception is a congenital condition where the layers of the intestinal wall do not form properly." Intussusception is not a congenital malformation but an acquired condition where one part of the intestine telescopes into another, causing obstruction and potential ischemia.
B. "Intussusception is a consequence of weakened abdominal muscles, allowing a portion of the intestine to bulge." This description is more characteristic of a hernia rather than intussusception, which involves the invagination of the intestine rather than a protrusion.
C. "Intussusception results from the twisting of the intestines, causing a blockage in the passage of food." Twisting of the intestines describes volvulus, a separate condition that can also cause bowel obstruction but occurs through a different mechanism than intussusception.
D. "Intussusception occurs when one segment of the intestine slides into another, which can cut off blood supply." This is the correct explanation. The telescoping of the intestine can cause bowel obstruction and compromise blood flow, leading to symptoms such as severe abdominal pain, vomiting, and the passage of red, currant jelly-like stools.
Correct Answer is B
Explanation
A. Cough, edema, and increased work of breathing. While these symptoms can indicate worsening heart failure, cough and edema are less prominent signs in infants compared to respiratory distress and feeding difficulties.
B. Tachypnea and diaphoresis with feeding, poor weight gain, and irritability. This is correct. Infants with worsening heart failure often struggle with feeding due to increased energy demands and difficulty breathing. Tachypnea (rapid breathing) and diaphoresis (excessive sweating) during feeding are classic early signs. Poor weight gain results from inadequate caloric intake, and irritability may be due to fatigue and hypoxia.
C. Abdominal pain, poor appetite, and cough. Abdominal pain is difficult to assess in infants, and poor appetite alone is not a definitive sign of heart failure. Cough may occur but is not a primary indicator of worsening heart failure in infants.
D. Bradycardia, rapid weight gain, and irritability. Bradycardia is not a common sign of worsening heart failure in infants; tachycardia (fast heart rate) is more typical. Rapid weight gain could suggest fluid retention but is not as reliable a sign as feeding difficulties and respiratory distress.
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