A child has come into the emergency department after a confirmed bite from a brown recluse. Which action can the nurse take to alleviate pain?
Place an ace wrap on the bite.
Administer Benadryl.
Elevate the affected area.
Apply a cool compress.
The Correct Answer is B
The correct answers are choices B. Administer Benadryl, and D. Apply a cool compress.
Choice A rationale:
Placing an ace wrap on the bite is not recommended for a brown recluse spider bite. This action could potentially worsen the situation as it might trap venom in the area and increase the risk of necrosis.
Choice B rationale:
Administering Benadryl is a suitable action for alleviating pain and managing allergic reactions related to the bite. Benadryl (diphenhydramine) is an antihistamine that can help reduce itching and inflammation.
Choice C rationale:
Elevating the affected area might not provide significant pain relief for a brown recluse spider bite. Elevating is generally more effective for reducing swelling associated with injuries involving fluid accumulation, like sprains or strains.
Choice D rationale:
Applying a cool compress to the bite area can help alleviate pain and reduce inflammation. Cold therapy constricts blood vessels, which can reduce swelling and numb the area, providing relief.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Epiglottitis.
Choice A rationale:
Laryngotracheobronchitis (LTB) is a viral infection commonly known as "croup." While it can cause airway inflammation and respiratory distress, it is usually not considered a medical emergency. LTB is characterized by barking cough, stridor, and hoarseness. It typically responds well to supportive care, humidity, and sometimes oral corticosteroids.
Choice B rationale:
Spasmodic croup is another type of viral croup, often triggered by allergies or irritants. It is characterized by sudden onset of symptoms, usually at night, including stridor and a barking cough. While it can be distressing, it is generally not considered a medical emergency. It usually responds to humidity and sometimes oral corticosteroids.
Choice C rationale:
Laryngitis involves inflammation of the larynx and is often caused by viral infections or excessive voice use. While it can lead to hoarseness and voice changes, it does not typically cause severe respiratory distress and is not considered a medical emergency. Resting the voice and staying hydrated are common interventions.
Choice D rationale:
Epiglottitis is a potentially life-threatening condition that causes inflammation of the epiglottis, a flap of tissue that prevents food from entering the windpipe during swallowing. It can rapidly progress to airway obstruction and respiratory failure. Children with epiglottitis often assume a "tripod" position, leaning forward to maintain an open airway. Immediate medical intervention, including securing the airway and administering antibiotics, is crucial.
Correct Answer is C
Explanation
The correct answer is choice C. Activity intolerance related to generalized weakness.
Choice A rationale:
Risk for injury related to depressed sensorium. This choice is not the most appropriate nursing diagnosis for a child with moderate anemia. While anemia can lead to fatigue and weakness, the main concern is the child's ability to tolerate physical activities, not the risk of injury due to a depressed sensorium.
Choice B rationale:
Decreased cardiac output related to abnormal hemoglobin. This choice is not the most suitable nursing diagnosis for a child with moderate anemia. While abnormal hemoglobin levels can affect cardiac output, moderate anemia typically doesn't lead to such a significant decrease in cardiac output that it becomes the primary nursing diagnosis. Activity intolerance is a more relevant concern.
Choice C rationale:
Activity intolerance related to generalized weakness. This is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia. Moderate anemia results in a decrease in oxygen-carrying capacity, leading to generalized weakness and reduced ability to perform physical activities without becoming fatigued. The child's hemoglobin levels are likely low enough to cause noticeable activity intolerance.
Choice D rationale:
Risk for Injury related to dehydration and abnormal hemoglobin. This choice is not the best nursing diagnosis for a child with moderate anemia. Dehydration may exacerbate the effects of anemia, but the primary issue here is the anemia itself causing weakness and activity intolerance, which are better addressed with the choice C diagnosis.
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