The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.
The parent reports no signs of watery stools.
What nursing intervention should the nurse implement?
Advise the parent to reduce the infant’s fruit intake for 24 hours.
Recommend the parent to clean with soap and water at each diaper change.
Instruct the parent to change the child’s diaper more frequently.
Encourage the parent to apply lotion with each diaper change.
The Correct Answer is C
Choice A rationale
Reducing the infant’s fruit intake for 24 hours is not the best approach in this situation. While certain fruits can cause diarrhea, the parent reports no signs of watery stools. Therefore, this intervention may not address the issue of the red and raw diaper area.
Choice B rationale
Cleaning with soap and water at each diaper change can actually worsen the condition. Soap can dry out the skin and disrupt the skin’s natural barrier, potentially leading to more irritation. It’s generally recommended to use water and a soft cloth, or a gentle non-soap cleanser, to clean the diaper area.
Choice C rationale
Changing the child’s diaper more frequently is the most appropriate intervention. A wet or dirty diaper can irritate the skin, leading to diaper rash. By changing the diaper more often, the skin is kept clean and dry, which can help the rash heal.
Choice D rationale
Applying lotion with each diaper change is not typically recommended for diaper rash. Some lotions can contain fragrances or other ingredients that can further irritate the rash. Instead, a barrier cream or ointment, such as one containing zinc oxide, is often recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Resuming normal physical activity is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of Diabetic Ketoacidosis (DKA). Physical activity can increase blood glucose levels, which could exacerbate the condition.
Choice B rationale
Administering a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a patient with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.
Choice C rationale
Consuming electrolyte fluid replacements is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While hydration is important, it does not address the underlying issue of high blood sugar levels.
Choice D rationale
Monitoring urine output over the next 24 hours is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While it is important to monitor urine output in patients with diabetes, it does not address the underlying issue of high blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale
The patient’s history indicates that she had difficulty breathing during a hike. This event led her to the emergency department. Difficulty breathing during physical activity such as hiking can be a symptom of an asthma exacerbation.
Choice B rationale
While severe allergic reactions can cause difficulty breathing, the patient’s history does not indicate that she experienced an allergic reaction prior to her emergency department visit.
Choice C rationale
Panic attacks can cause symptoms such as rapid heart rate, sweating, and shortness of breath. However, the patient’s history does not indicate that she had a panic attack prior to her emergency department visit.
Choice D rationale
Fainting, or loss of consciousness, can be caused by various conditions, including dehydration, low blood sugar, and heart problems. However, the patient’s history does not indicate that she fainted prior to her emergency department visit.
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