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.

Restrict oral fluids to 500 mL per day.

Report the diagnosis to the public health department.

Answer and Explanation

The Correct Answer is D

A. Placing the child in a protected environment for 48 hours is not a necessary measure for managing pertussis. Pertussis is transmitted through respiratory droplets, and standard precautions are typically sufficient.

B. Administering the pertussis vaccine is a preventive measure, but it is not a treatment for an active infection. In this case, the child already has pertussis, so administering the vaccine will not address the current illness.

C. Restricting oral fluids to 500 mL per day is not a recommended intervention for pertussis. Maintaining hydration is important, and fluid intake should be based on the child's needs.

D. This is the correct action. Reporting the diagnosis of pertussis to the public health department is a crucial step in preventing the spread of the disease. It allows for contact tracing and appropriate public health measures to be implemented to limit further
transmission.

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Correct Answer is A

Explanation

A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.

A. Abrasions on the knees B. Front deciduous teeth missing C. Weight in 45th percentile D. Bruising around the wrists

Correct Answer is D

Explanation

A. Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.

B. Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.

C. Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.

D. Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.

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A nurse is caring for a school-age child who has pertussis. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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