The nurse is assessing a pediatric client and notes crop lesions that have spread to the face, trunk, and arms. Some appear as a pruritic macular rash and others have started to develop into vesicles. What intervention(s) will the nurse implement? (Select all that apply)

Implement standard precautions and guidelines only.

Place the child in a tepid bath to decrease pruritis.

Strict airborne and contact isolation precautions.

Allow unexposed friends of the child to come visit.

Strict droplet precautions and enforce handwashing

Answer and Explanation

Correct Answer : B,C

A. Standard precautions alone are not sufficient, because varicella (chickenpox) is highly contagious and requires additional infection control measures.
B. Tepid baths and soothing topical applications such as calamine lotion can help relieve pruritus and discomfort from vesicular lesions.
C. Varicella is transmitted by airborne droplets and direct contact with lesions; therefore, strict airborne and contact isolation is required until all lesions have crusted over.
D. Unexposed friends should not visit, as the virus spreads easily to anyone who is not immune.
E. While hand hygiene is important, varicella is not controlled with droplet precautions alone; airborne and contact isolation is necessary.

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Correct Answer is A

Explanation

A. A client with Parkinson’s disease who urgently needs to use the bathroom is at high risk for falls due to rigidity, tremors, and shuffling gait. Needing to move quickly to the bathroom further increases the risk of injury, making this the priority for immediate assessment and assistance.
B. Refusing bisphosphonate therapy for osteoporosis is important to address but does not present an immediate safety risk requiring urgent assessment.
C. A client who is 3 days post–hip fracture surgery requires ongoing monitoring, but this is expected care and not an immediate fall or injury risk compared with the Parkinson’s client.
D. An older adult ambulating may need monitoring for safety, but unless new symptoms arise, this does not pose the same level of urgency as the Parkinson’s client who needs urgent toileting.

A. A client with cholecystitis who is nauseous when they eat fatty foods. B. A client with bronchitis who has a productive cough. C. A client with appendicitis who has a rigid abdomen and a temperature. D. A client with nephritis and a urine output of 30mL/hour.

Correct Answer is C

Explanation

A. Nausea with fatty foods is expected in cholecystitis and does not indicate immediate life-threatening complications.

B. A productive cough in bronchitis requires monitoring and supportive care, but it is not the most urgent concern.

C. Rigid abdomen and fever in appendicitis indicate peritonitis, a surgical emergency. This client is at highest risk for sepsis and requires immediate assessment and intervention.

D. Urine output of 30 mL/hour is low but not immediately life-threatening compared to peritonitis; it requires monitoring and possible intervention but is less urgent.

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Heart Rate	115 beats per minute
Blood pressure	100/70 mmHg
Temperature	98.7 F (37.0 C)
Oxygen saturation	90% on room air

The nurse is assessing a pediatric client and notes crop lesions that have spread to the face, trunk, and arms. Some appear as a pruritic macular rash and others have started to develop into vesicles. What intervention(s) will the nurse implement? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is receiving morning report on several clients with mobility concerns. Which client is the priority for the nurse to assess?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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