A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?
Place the child in a protected environment for 48 hr
Administer the pertussis vaccine.
Report the diagnosis to the public health department.
Restrict oral fluids to 500 mL per day.
The Correct Answer is C
A. Place the child in a protected environment for 48 hr: While isolation might be implemented, 48 hours is not a typical timeframe for pertussis. The contagious period can last for weeks.
B. Administer the pertussis vaccine: The pertussis vaccine is for prevention, not treatment of an active case.
C. Report the diagnosis to the public health department. Pertussis, also known as whooping cough, is a highly contagious respiratory illness. Reporting the case to the public health department allows them to track the spread of the disease and take steps to prevent further outbreaks
D. Restrict oral fluids to 500 mL per day. Restricting fluids can worsen dehydration, especially in a child with a respiratory illness.
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Related Questions
Correct Answer is B
Explanation
A. Weight loss of 5%: A 5% weight loss is typically indicative of mild to moderate dehydration, not severe.
B. Sunken anterior fontanelle: A sunken anterior fontanel is a sign of severe dehydration in infants as it indicates significant fluid loss.
C. Produces tears when crying: Producing tears is a sign of adequate hydration. Absence of tears would be more concerning for dehydration.
D. Capillary refill time 3 seconds: A capillary refill time of 3 seconds is at the upper limit of normal for infants. In severe dehydration, capillary refill time would typically be longer than 3 seconds.
Correct Answer is D
Explanation
A. An adolescent who has a BP of 132/82 mm Hg: While on the higher end of normal for adolescents, it might not necessarily require immediate reporting unless there are other symptoms or a history of hypertension.
B. A 3-month-old infant who has a respiratory rate of 30/min: A respiratory rate of 30/min is within the normal range for a 3-month-old infant. Normal respiratory rates for infants typically range from 30 to 60 breaths per minute
C. A school-age child who has a rectal body temperature of 37.3° C (99.1° F): This is a low-grade fever and might not be a major concern in an otherwise healthy school-age child.
D. An 18-month-old toddler who has a heart rate of 68/min: A heart rate of 68/min is lower than the normal range for an 18-month-old toddler. Typically, the normal heart rate for toddlers ranges from about 80 to 130 beats per minute. A heart rate of 68/min could indicate bradycardia, which requires further assessment by a provider.
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