A nurse is caring for a school-age child who has heart failure. Which of the following interventions should the nurse implement?
Avoid giving the child live virus vaccines.
Weigh the child every other day.
Ensure that the child sleeps in an air-conditioned room.
Consolidate activities to promote the child's rest.
The Correct Answer is D
A. Avoid giving the child live virus vaccines. Children with heart failure can receive live vaccines unless they are immunocompromised (e.g., from immunosuppressive therapy).
B. Weigh the child every other day. Daily weights are necessary to monitor fluid retention, a key concern in heart failure.
C. Ensure that the child sleeps in an air-conditioned room. While a cool environment may be comfortable, this is not a priority intervention for heart failure management.
D. Consolidate activities to promote the child's rest. Children with heart failure experience fatigue easily due to reduced cardiac output. Grouping activities together minimizes energy expenditure and promotes adequate rest.
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Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Explanation
Disseminated Intravascular Coagulation (DIC)- Bacterial meningitis can lead to septicemia, which may trigger DIC. Petechiae or purpura (noted earlier) suggest potential coagulation abnormalities. DIC results in widespread clotting and subsequent bleeding, which can be life-threatening.
Hydrocephalus- Meningeal inflammation can obstruct cerebrospinal fluid (CSF) flow, leading to increased intracranial pressure (ICP). Symptoms such as headache, lethargy, irritability, and nuchal rigidity suggest increased ICP and potential hydrocephalus development.
Hypothermia- The child presents with fever (38.7°C/101.7°F), which is typical in bacterial infections rather than hypothermia. Septic shock can cause hypothermia in late stages, but early-stage bacterial meningitis more commonly causes fever.
Correct Answer is A
Explanation
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
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