Parents report their 3-year-old child appears restless at night and frequently scratches her anal area. What action by the nurse is best?
Review hygiene practices with the parents.
Suggest the child sleep only in pajama tops.
Ask parents to bring in a stool sample.
Educate parents on the cellophane tape test.
The Correct Answer is D
A. While reviewing hygiene practices is important, it does not confirm the cause of the nighttime anal itching, which could be due to pinworm infection.
B. Limiting clothing is not an effective diagnostic or treatment measure for suspected pinworm infection.
C. A stool sample is not reliable for diagnosing pinworms, as eggs are laid around the anus at night, not in stool.
D. The cellophane tape test is the preferred diagnostic method for Enterobius vermicularis (pinworm). It involves placing clear tape on the perianal area in the morning to collect eggs for microscopic examination, allowing accurate diagnosis and appropriate treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Uterine enlargement greater than expected is typical of a normal intrauterine pregnancy, as the uterus grows to accommodate the developing fetus. In ectopic pregnancy, the uterus may remain small because implantation occurs outside the uterine cavity.
B. Severe nausea and vomiting are common in normal early pregnancy due to hormonal changes, but they are not specific indicators of ectopic pregnancy.
C. Unilateral, cramp-like abdominal pain is a hallmark sign of ectopic pregnancy, often caused by the distension or irritation of the fallopian tube where the fertilized ovum implants. Pain may be sharp or colicky and localized to one side.
D. Vaginal bleeding in ectopic pregnancy is usually light, often described as spotting, and may be accompanied by abdominal pain. A large amount of bleeding is less common unless tubal rupture occurs, which represents a medical emergency requiring immediate intervention.
Correct Answer is C
Explanation
A. Nervousness occurs due to terbutaline’s stimulation of beta-adrenergic receptors, which can increase sympathetic activity. This is generally mild and expected, requiring only reassurance and monitoring.
B. Tremors are a common side effect from beta-2 adrenergic stimulation of skeletal muscles. They are usually transient and non-dangerous, not requiring immediate intervention.
C. Dyspnea may indicate pulmonary edema, a potentially life-threatening complication associated with terbutaline therapy, especially if used for prolonged periods or in clients with cardiac or renal compromise. Prompt recognition and immediate reporting to the provider is essential to prevent serious maternal and fetal complications.
D. Headaches may occur due to vasodilation and increased cardiac output, but they are typically mild and self-limiting, not a sign of severe adverse effect.
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