A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?
"My child has some swelling around her eyelids and mouth."
"My child has a temperature of 100.7 degrees Fahrenheit."
"My child only ate 2 ounces during her last feeding."
"My child cries when I touch the area where she received the shot.".
The Correct Answer is A
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
Correct Answer is A
Explanation
Choice A rationale:
Hypertension is a common manifestation of acute glomerulonephritis. The inflammation of the glomeruli in the kidneys can lead to impaired filtration, causing fluid retention and an increase in blood pressure. Monitoring the child's blood pressure is crucial to assess the severity of the condition and guide appropriate interventions.
Choice B rationale:
Dehydration is not a typical manifestation of acute glomerulonephritis. In fact, this condition often leads to fluid retention due to impaired kidney function. The child might experience edema and hypertension rather than dehydration.
Choice C rationale:
Muehrcke lines on the nails are not associated with acute glomerulonephritis. Muehrcke lines are white lines that appear horizontally across the nails and are typically indicative of hypoalbuminemia, which is not a primary feature of glomerulonephritis.
Choice D rationale:
Hypokalemia, or low potassium levels, is not a characteristic manifestation of acute glomerulonephritis. This condition primarily affects the kidneys' ability to filter waste and excess fluid, leading to fluid retention, electrolyte imbalances, and hypertension.
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