The clinic nurse receives a call from a parent of a 10-year-old who reports that their child just returned from summer camp and has developed an expanding circular red rash on the arm. The parent asks the nurse which over-the-counter (OTC) product is safe to use. How should the nurse respond?
Encourage the parent to come to the clinic if the child develops a fever.
Instruct the parent to apply an antihistamine ointment for one week.
Offer reassurance that OTC corticosteroid creams are safe and effective.
Explain the need for the child to have an immediate medical evaluation.
The Correct Answer is D
Choice A reason: Encouraging the parent to come to the clinic if the child develops a fever is not the best response that the nurse can give. This is because a fever may indicate a serious infection, such as Lyme disease, that requires prompt treatment. The nurse should not wait for the child to develop a fever before advising the parent to seek medical attention.
Choice B reason: Instructing the parent to apply an antihistamine ointment for one week is not the best response that the nurse can give. This is because an antihistamine ointment may not be effective for a fungal infection, such as ringworm, or a bacterial infection, such as Lyme disease, that may cause a circular rash. The nurse should not recommend any OTC product without knowing the exact cause of the rash.
Choice C reason: Offering reassurance that OTC corticosteroid creams are safe and effective is not the best response that the nurse can give. This is because corticosteroid creams may worsen a fungal infection, such as ringworm, or mask the symptoms of a bacterial infection, such as Lyme disease, that may cause a circular rash. The nurse should not recommend any OTC product without knowing the exact cause of the rash.
Choice D reason: Explaining the need for the child to have an immediate medical evaluation is the best response that the nurse can give. This is because a circular rash can be a sign of a serious condition, such as Lyme disease, that requires urgent diagnosis and treatment. The nurse should inform the parent that the rash may not be ringworm, as many people assume, and that it may be caused by a tick bite or another factor. The nurse should also advise the parent to avoid touching or scratching the rash and to keep it clean and dry until the child sees a doctor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat heart failure in infants. It lowers blood pressure and reduces the workload of the heart. Enalapril is not contraindicated in this scenario and does not need to be withheld.
Choice B reason: Digoxin is a cardiac glycoside that is used to treat heart failure and arrhythmias in infants. It increases the contractility of the heart and slows down the heart rate. Digoxin has a narrow therapeutic range and can cause toxicity if the dose is too high or the infant is dehydrated. Digoxin should be withheld if the infant's apical pulse is less than 90 beats/minute, which is the case in this scenario. The nurse should notify the health care provider and monitor the infant for signs of digoxin toxicity, such as nausea, vomiting, bradycardia, and visual disturbances.
Choice C reason: Hydralazine is a vasodilator that is used to treat hypertension and heart failure in infants. It lowers blood pressure and reduces the afterload of the heart. Hydralazine is not contraindicated in this scenario and does not need to be withheld.
Choice D reason: Furosemide is a loop diuretic that is used to treat fluid overload and edema in infants with heart failure. It lowers blood pressure and reduces the preload of the heart. Furosemide is not contraindicated in this scenario and does not need to be withheld
Correct Answer is D
Explanation
Choice A reason: Changing position every 2 hours is not the most important intervention that the nurse should implement. This is because the child's position is limited by the traction and the splint, and frequent repositioning may interfere with the alignment and stability of the fracture. The nurse should only change the position of the child as ordered by the physician and with the assistance of another nurse.
Choice B reason: Assessing skin for redness and signs of tissue breakdown is not the most important intervention that the nurse should implement. This is because the skin is not directly in contact with the traction or the splint, and the risk of pressure ulcers is low. The nurse should still inspect the skin regularly and provide skin care as needed, but this is not the priority.
Choice C reason: Cleansing pin sites as prescribed is not the most important intervention that the nurse should implement. This is because the pin sites are not the main source of infection or complication in this type of traction. The nurse should still follow the protocol for pin site care and monitor for signs of infection, such as redness, swelling, drainage, or odor, but this is not the priority.
Choice D reason: Monitoring peripheral pulses and sensation in the right leg is the most important intervention that the nurse should implement. This is because the traction and the splint can impair the circulation and nerve function of the affected extremity, leading to complications such as compartment syndrome, ischemia, or nerve damage. The nurse should check the pulses, temperature, color, capillary refill, and sensation of the right leg at least every hour and report any changes or abnormalities to the physician.
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