A nurse is preparing a teaching plan for the care of a child with infantile eczema.
What interventions would the nurse include? (Select all that apply.)

Choice A rationale

The presence of white flakes that are difficult to brush off the hair is a classic sign of pediculosis capitis, also known as head lice. These flakes are nits, or lice eggs, which are cemented to the hair shaft and are not easily removed. The rash on the back of the neck is often a result of scratching or an allergic reaction to the lice saliva.

Choice B rationale

Impetigo contagiosa is a highly contagious bacterial skin infection characterized by red sores that quickly rupture, ooze for a few days, and then form a honey-colored crust. It typically does not present with white flakes in the hair.

Choice C rationale

Folliculitis is an inflammation of the hair follicles, often caused by a bacterial or fungal infection. It presents as small, red pimples with a hair in the center. It is not associated with white flakes or nits in the hair.

Choice D rationale

Tinea capitis, a fungal infection of the scalp, is characterized by scaly patches of temporary baldness. It may cause inflammation and itching, but it does not produce the characteristic white flakes or nits that adhere to the hair shaft.

Choice A rationale

Administering pain medication addresses the subjective symptom but does not address the underlying physiological cause, which could be a critical limb-threatening complication like acute limb ischemia. The priority is to assess for objective signs of vascular compromise to ensure the graft's patency and prevent irreversible tissue damage from prolonged ischemia.

Choice B rationale

Assessing distal pulses and skin color is the most critical action to evaluate the patency of the newly created bypass graft. A sudden decrease in blood flow, indicated by diminished pulses and pallor, is a sign of graft occlusion, which is a surgical emergency requiring immediate intervention to restore perfusion and prevent tissue necrosis.

Choice C rationale

Documenting the findings is an essential step in the nursing process, but it is not the most important immediate action. Documentation should follow a thorough assessment and any necessary interventions. Failure to assess the graft's patency first could delay a time-sensitive intervention and lead to irreversible limb damage.

Choice D rationale

Notifying the surgeon is a necessary step if objective signs of graft occlusion are found. However, this action should follow a focused assessment. The nurse must first gather objective data, such as pulse quality and skin color, to provide a complete and accurate report to the surgeon, guiding their decision-making process.