A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
Provide the child with a warm blanket.
Assess the oral cavity for Koplik spots.
Administer aspirin for fever.
Initiate airborne precautions.
The Correct Answer is D
Rationale:
A. Providing the child with a warm blanket can help keep the child comfortable during the course of the illness but initiating airborne precautions is best intervention required.
B. Assessing the oral cavity for Koplik spots is not relevant for varicella, as Koplik spots are associated with measles.
C. Administering aspirin for fever is contraindicated in children with varicella due to the risk of Reye's syndrome.
D. The nurse should initiate airborne precautions, which include placing the child in a private room with negative air pressure, wearing a mask or respirator when entering the room, and limiting visitors and staff exposure. Airborne precautions prevent the transmission of varicella through small droplets that can remain suspended in the air for long periods of time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications.
B. Restricting strenuous activities is important for preventing damage to the cast, but it is not the priority over monitoring for circulatory compromise.
C. Monitoring for pallor or swelling in the child's affected hand is the priority because it indicates potential circulatory compromise, which is a critical concern following cast application.
D. Using a hair dryer on a cool setting to relieve itching is a helpful suggestion, but it is not the priority over monitoring for potential complications.
Correct Answer is D
Explanation
A) Abrasions on the knees could result from normal childhood activities and may not indicate physical abuse.
B) Front deciduous teeth missing could be due to normal tooth loss.
C) Weight in the 45th percentile is within a normal range and does not necessarily indicate physical abuse.
D) Bruising around the wrists is concerning for physical abuse, especially in a pattern consistent with restraining or gripping.
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