A nurse is caring for a preschooler who is terminally ill.Which of the following reactions to death should the nurse expect?

Choice C rationale

Hives on the child's neck is the priority finding because it can indicate an allergic reaction, which may progress to anaphylaxis. Anaphylaxis is a severe, life-threatening allergic reaction that requires immediate intervention. Hives are often the first sign of an allergic reaction and can quickly escalate to airway obstruction, difficulty breathing, and cardiovascular collapse. Early identification and treatment of an allergic reaction can prevent these severe complications. The nurse should be prepared to administer emergency medications, such as epinephrine, and provide respiratory support if needed.

Choice A rationale

Redness at the injection site is a common and expected local reaction following immunization. It typically resolves on its own without intervention. While it may cause some discomfort, it does not pose an immediate threat to the child's health and is not a priority over signs of a potential allergic reaction.

Choice B rationale

A temperature of 37.7°C (99.9°F) is a mild fever and a common response to immunizations as the body mounts an immune response. It is not usually cause for concern and can be managed with antipyretics if necessary. This mild fever does not indicate an urgent condition compared to the signs of an allergic reaction.

Choice D rationale

Prolonged crying can be a sign of discomfort or pain following an immunization but is not necessarily indicative of a severe reaction. It is important to assess the child's overall condition and provide comfort measures. However, it does not take precedence over signs of an allergic reaction, which require immediate attention.

Choice A rationale

Ensuring that the balls of your feet touch the ground when seated on the bicycle can actually indicate that the bicycle is too small. Proper bicycle fitting for children is essential for both comfort and safety. The balls of the feet should only touch the ground when the child is off the saddle, indicating that the seat height allows for proper leg extension while pedaling. This helps in efficient pedaling and reduces the risk of knee injuries.

Choice B rationale

Choosing a helmet that is light in color and covers your ears is important for bicycle safety. A light-colored helmet increases visibility to motorists, especially in low-light conditions, reducing the risk of accidents. Helmets should fit snugly and cover the forehead without obstructing the ears, ensuring they remain in place during a fall or collision. This protection is crucial to prevent head injuries, which can be severe and life-threatening in the event of an accident.

Choice C rationale

Riding a bicycle through crosswalks and intersections instead of walking it increases the risk of accidents. Pedestrians have the right of way in crosswalks, and riding through them can lead to collisions with both vehicles and pedestrians. Walking the bicycle allows the rider to better observe traffic signals, check for oncoming vehicles, and make safer decisions, thus significantly reducing the risk of accidents and ensuring the safety of all road users.

Choice D rationale

Riding against traffic to allow visibility to oncoming vehicles is extremely dangerous and against most traffic laws. Bicycle riders should ride with the flow of traffic to avoid head-on collisions and ensure predictability for other road users. Oncoming traffic may not expect a bicycle in their lane, increasing the risk of accidents. Riding with traffic helps to follow the same signals and signs as motor vehicles, ensuring better integration and safety on the road.