A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infant's neck and axilla. What does the nurse explain as the most likely cause of this rash?

Sun exposure

Allergic reaction

Infection

Heat and moisture

Answer and Explanation

The Correct Answer is D

A. Sun exposure: Sun exposure typically causes sunburn rather than tiny pinhead-sized papules.
B. Allergic reaction: Allergic reactions often present with different types of lesions or hives, not typically tiny papules.
C. Infection: Infections might cause different types of lesions or pustules rather than the described tiny papules.
D. Heat and moisture: Heat rash (miliaria) results from blocked sweat ducts, leading to tiny red papules due to overheating and trapped sweat, commonly occurring in areas like the neck and axilla.

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Correct Answer is B

Explanation

A. Maculopapular lesions behind the ears: Maculopapular lesions are not characteristic of head lice infestation.
B. White sacs attached to the hair shafts in the occipital area: White sacs (nits) attached to hair shafts are characteristic of head lice infestation.
C. White flaky particles throughout the entire scalp region: White flaky particles are more suggestive of dry scalp or dandruff, not head lice.
D. Lesions in the scalp that extend to the hairline or neck: Lesions extending to the hairline or neck could indicate secondary infection but are not specific to head lice infestation.

A. Test the urine for ketones. B. Withhold insulin dose if feeling nauseous. C. Notify the provider if blood glucose levels are over 350 mg/dL. D. Limit fluid intake during meal time.

Correct Answer is C

Explanation

A. Test the urine for ketones. While testing for ketones can be part of illness management in diabetes, it is not as immediate an action as contacting a healthcare provider when blood glucose levels are very high.
B. Withhold insulin dose if feeling nauseous. Insulin should not be withheld due to nausea. It is important to maintain insulin to control blood glucose levels even when feeling unwell. Adjustments to insulin may be necessary based on blood glucose levels and food intake.
C. Notify the provider if blood glucose levels are over 350 mg/dL. Blood glucose levels over 350 mg/dL are concerning and may indicate the need for medical intervention to prevent complications like diabetic ketoacidosis. The healthcare provider should be notified.
D. Limit fluid intake during meal time. Adequate fluid intake is important, especially when blood glucose levels are high, to help prevent dehydration and facilitate glucose clearance. Limiting fluids is not appropriate.

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A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infant's neck and axilla. What does the nurse explain as the most likely cause of this rash?

Nursing Test Bank

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