The nurse is assisting in planning care for the child.
Which of the following interventions should the nurse plan to include?
Obtain daily weights.
Obtain blood pressure every 8 hours.
Maintain seizure precautions.
Maintain a sodium-restricted diet.
The Correct Answer is C
Choice A rationale
Daily weights are primarily used for fluid balance monitoring, especially in cases like heart failure or renal conditions. It is not a standard intervention unless specifically indicated for the child’s clinical condition.
Choice B rationale
Routine blood pressure checks every 8 hours are not typically necessary for pediatric patients unless there is a concern for hypertension or critical illness. This intervention is not universally applicable.
Choice C rationale
Seizure precautions are crucial for ensuring patient safety in children with a history or risk of seizures. They include measures such as padded side rails, oxygen availability, and maintaining a safe environment.
Choice D rationale
Sodium-restricted diets are not routinely prescribed for children unless there is an underlying condition like kidney or cardiac disease. This intervention does not apply broadly to pediatric care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Dehydration generally leads to a decrease in blood pressure due to reduced intravascular volume. Hypovolemia causes compensatory mechanisms like tachycardia rather than increased blood pressure.
Choice B rationale
A flat anterior fontanel is a normal finding in toddlers and does not indicate dehydration. Dehydration is more likely to cause sunken fontanels due to tissue fluid loss and reduced intracranial pressure.
Choice C rationale
Increased pulse occurs as the heart compensates for hypovolemia caused by dehydration. The body attempts to maintain adequate oxygen delivery to tissues by enhancing cardiac output through tachycardia. This compensatory mechanism is a key indicator of dehydration.
Choice D rationale
Distended jugular veins suggest elevated central venous pressure, commonly seen in fluid overload rather than dehydration. Dehydration reduces venous return, leading to less prominent veins.
Correct Answer is A
Explanation
Choice A rationale
Clostridium difficile requires contact precautions due to high transmissibility through direct or indirect contact with infected surfaces.
C. difficile spores are resistant to standard disinfectants, necessitating rigorous hand hygiene and barrier protections. Contact precautions minimize spread within healthcare settings, essential for controlling this infectious pathogen.
Choice B rationale
Streptococcal pharyngitis is transmitted via respiratory droplets rather than contact surfaces. Droplet precautions are sufficient for preventing spread. Using contact precautions would unnecessarily restrict healthcare operations, diverging from established infection control practices.
Choice C rationale
Haemophilus influenzae transmission occurs primarily through respiratory droplets, requiring droplet precautions. Contact precautions do not address its aerosolized nature effectively, reducing their utility. Droplet control methods align with evidence-based recommendations for minimizing spread.
Choice D rationale
Mycoplasma pneumoniae spreads predominantly through droplets during coughing or sneezing, necessitating droplet precautions rather than contact measures. Respiratory isolation procedures focus on limiting droplet exposure to control transmission.
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