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: Jaundice.
Choice A rationale:
Vomiting can occur in biliary atresia due to the blockage of bile flow, but it is not the earliest clinical manifestation. Jaundice tends to precede vomiting and is a more characteristic early sign of biliary atresia.
Choice B rationale:
Hepatomegaly (enlargement of the liver) is a common finding in biliary atresia, but it usually occurs after the onset of jaundice. Jaundice is an earlier and more specific manifestation of this condition.
Choice C rationale:
Absence of stooling is a sign that might occur in biliary atresia due to the obstructed bile flow, but it is not typically the earliest clinical manifestation. Jaundice is generally the first noticeable sign.
Choice D rationale:
Jaundice is the earliest clinical manifestation of biliary atresia. It is caused by the buildup of bilirubin in the blood due to impaired bile flow from the liver. The jaundice in biliary atresia is typically progressive and can be one of the key indicators for further evaluation and diagnosis.
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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