While conducting a head lice screening for third-grade students, the school nurse notices a brownish thickening on the neck of one child.
What should be the nurse’s response to this observation?

Answer and explanation

The correct answer is Choice D.

Choice A rationale

While reminding drivers to wear seatbelts is important for overall road safety, it does not directly enhance the safety of children walking to and from school.

Choice B rationale

Advising residents to keep their porch lights on can improve visibility during hours of low light. However, this measure may not significantly enhance the safety of children walking to and from school during daylight hours.

Choice C rationale

Encouraging residents to have their homes inspected for high lead levels is important for overall community health, but it does not directly impact the safety of children walking to and from school.

Choice D rationale

Facilitating a discussion about the advantages of having designated safe houses located throughout the school neighborhood can significantly enhance the safety of children walking to and from school. Safe houses can provide a secure place for children to go if they feel threatened or in danger while walking to or from school.

Answer and explanation The correct answer is D. Choice A rationale

Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.

Choice B rationale

Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.

Choice C rationale

Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.

Choice D rationale

Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.