A pre-school age child is admitted with a febrile seizure. The practical nurse (PN) obtains an oral temperature of 104.2° F (40.1° C) during the morning assessment. Which action should the PN prepare to implement?
Provide a tepid sponge bath.
Remove blankets while shivering.
Apply blankets during diaphoresis.
Turn on an oscillating fan.
The Correct Answer is A
A. Provide a tepid sponge bath: Providing a tepid sponge bath is an effective non-pharmacological intervention to help lower a dangerously high fever in a child. This method promotes gentle cooling by encouraging heat loss through evaporation, helping reduce the risk of another seizure without causing abrupt temperature changes.
B. Remove blankets while shivering: Removing blankets while the child is actively shivering is not recommended because shivering can increase the body's metabolic rate and paradoxically raise the core temperature. Managing the fever should focus on gradual cooling without triggering additional metabolic heat production.
C. Apply blankets during diaphoresis: Applying blankets during diaphoresis, when the child is already sweating, can trap heat and counteract the body's natural efforts to cool down. During diaphoresis, lighter coverings or removing excess clothing is more appropriate to facilitate heat loss.
D. Turn on an oscillating fan: Although using a fan can aid in cooling by promoting air circulation, it can also cause rapid cooling, leading to shivering. Shivering increases metabolic heat production, which may worsen the child's condition during a febrile episode rather than improving it.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Wash around the catheter insertion site with soap and water: A condom catheter does not involve an insertion site into the urethra. This action applies to indwelling urinary catheters, not external devices like a condom catheter.
B. Cleanse around the condom with an antibacterial cleansing agent: Cleaning around the condom itself does not address hygiene properly. The condom must be removed to thoroughly cleanse the skin underneath and prevent moisture buildup and skin breakdown.
C. Remove the condom and cleanse the penis with soapy water: Removing the condom daily and gently cleaning the penis with mild soapy water helps maintain hygiene, reduces the risk of skin irritation, and prevents infection, which are key aspects of proper condom catheter care.
D. Loosen the condom and apply an antibacterial ointment: Applying ointment under a condom catheter can create a moist environment that promotes bacterial growth and skin breakdown. Proper hygiene focuses on cleansing and keeping the skin dry and intact.
Correct Answer is C
Explanation
A. Check for external rectal hemorrhoids: Hemorrhoids may cause discomfort during diarrhea, but they are not the most urgent concern. The primary issue with severe diarrhea is the risk of dehydration and electrolyte imbalance, which can become life-threatening.
B. Note inflammation in the perineal area: While important for skin care and comfort, perineal inflammation does not pose the immediate systemic risk that fluid volume deficit does. Skin assessment can be addressed after ensuring the client's vital signs and hydration status are stable.
C. Observe for signs of fluid volume deficit: Severe diarrhea leads to significant fluid and electrolyte losses. Signs such as hypotension, tachycardia, dry mucous membranes, and decreased urine output indicate fluid volume deficit, which requires urgent intervention to prevent shock and organ dysfunction.
D. Determine any changes in sleep patterns: Sleep disturbances can occur with illness but are not as immediately critical to assess as fluid and electrolyte status. Identifying fluid volume deficit must be prioritized to prevent rapid clinical deterioration.
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