A nurse is contributing to the plan of care for a preschooler who has moderate partial- thickness burns on both lower extremities. Which of the following interventions should the nurse recommend?
Maintain clean technique during the child's dressing changes.
Provide low-calorie snacks for the child three to four times each day between meals.
Allow the child to set their own daily schedule for wound care.
Ensure the child receives pain medication 30 to 45 min prior to therapy.
The Correct Answer is D
Rationale:
A) Maintaining clean technique during dressing changes is essential for preventing infection but is not specific to pain management.
B) Providing low-calorie snacks is unrelated to managing moderate partial-thickness burns.
C) Allowing the child to set their own schedule for wound care might not be appropriate or safe, as wound care should be performed according to healthcare provider recommendations.
D) Ensuring the child receives pain medication prior to therapy helps manage pain associated with dressing changes and other therapeutic interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale for A: If the child can describe what frightened them, this would be more consistent with nightmares. Nightmares often involve the ability to recall details of the bad dream, whereas sleep terrors are typically associated with no memory of the event.
Rationale for B: Children with sleep terrors generally do not fully awaken and can usually go back to sleep immediately. This is a key distinction between sleep terrors and nightmares, where the child remains distressed for some time and may be hesitant to fall back asleep.
Rationale for C: Becoming fully awake and in a panic is more characteristic of nightmares, where the child may wake up terrified and struggle to calm down, unlike sleep terrors where they do not fully awaken.
Rationale for D: A child with nightmares is often easily comforted by the presence of a parent. In contrast, children with sleep terrors are difficult to comfort because they are not fully awake and may not respond to soothing efforts.
Correct Answer is D
Explanation
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
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