The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing intervention is the highest priority for this child?

The nurse applies elbow restraints to the infant.

The nurse soaks the skin with warm water.

The nurse follows contact precautions.

The nurse applies topical antibiotics to the lesions.

Answer and Explanation

The Correct Answer is C

A. The nurse applies elbow restraints to the infant:

The use of elbow restraints is not a standard intervention for impetigo. Restraints are typically used for specific medical reasons, such as preventing the infant from interfering with medical equipment or procedures. It is not the highest priority in managing impetigo.

B. The nurse soaks the skin with warm water:

Soaking the skin with warm water can help in keeping the affected areas clean and promoting healing, but it is not the highest priority when considering the prevention of the spread of impetigo.

C. The nurse follows contact precautions:

Following contact precautions is the highest priority when dealing with impetigo. Since impetigo is highly contagious, implementing contact precautions, such as wearing appropriate PPE, is crucial to prevent the spread of the infection within the hospital setting.

D. The nurse applies topical antibiotics to the lesions:

Applying topical antibiotics is an important part of the treatment for impetigo. It helps to eliminate the bacterial infection and promote healing. However, while important, it is not the highest priority compared to preventing the spread of the infection through contact precautions.

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Correct Answer is B

Explanation

A. The mother opens the capsule and some medication spills on the fingers:

Pancreatic enzymes are usually taken intact, and their contents are meant to be sprinkled on soft food, not opened and spilled. This observation suggests a misunderstanding of the proper administration.

B. The child takes a dose before having an afternoon snack.

In cystic fibrosis, pancreatic enzyme replacement therapy is commonly used to help digest and absorb nutrients. The enzymes are typically taken with meals and snacks to aid in the digestion of food.

C. The child chews an enteric form of the medication:

Pancreatic enzymes are usually enteric-coated to protect them from stomach acid, and they are not meant to be chewed. Chewing can reduce their effectiveness. This observation indicates a need for clarification on administration.

D. The father tells the child that diarrhea is expected with this medication:

While gastrointestinal side effects can occur with pancreatic enzyme use, persistent diarrhea may indicate a dosage issue or other problems. It's important to address this with the healthcare provider. The statement suggests a potential misunderstanding or need for clarification.

A. “My child has a vocabulary of approximately 20 words.” B. “My child is still thumb sucking.” C. “My child seems to be quite wary of strangers.” D. “My child is able to stand but is not yet taking steps independently.”

Correct Answer is D

Explanation

A. “My child has a vocabulary of approximately 20 words.”

This statement indicates language development, and an 18-month-old with a vocabulary of approximately 20 words is within the expected range. It's a positive indicator of language acquisition.

B. “My child is still thumb sucking.”

Thumb sucking is a common self-soothing behavior in infants and toddlers. While it's a normal behavior, it typically decreases with age. Thumb sucking alone may not necessarily be a cause for concern unless it persists significantly and interferes with other aspects of development.

C. “My child seems to be quite wary of strangers.”

Stranger anxiety is a normal developmental stage, and many children exhibit wariness or fear of unfamiliar people around the age of 18 months. It is considered a typical response and not necessarily indicative of developmental delay.

D. “My child is able to stand but is not yet taking steps independently.”

At 18 months, most children are expected to be walking independently. The inability to take independent steps might be a concern for gross motor skill development. While some variation is normal, a delay in achieving this milestone might prompt further evaluation to rule out any underlying developmental issues.

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The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing intervention is the highest priority for this child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating teaching provided to a school-age child and parents about the use of pancreatic enzymes for cystic fibrosis. Which observation indicates that teaching has been effective?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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