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 A
Explanation
Choice A rationale:
Maintaining oral rehydration therapy is a crucial nursing action when caring for a child with shigella, which is a bacterial infection that causes severe diarrhea. Oral rehydration therapy helps prevent dehydration and electrolyte imbalances caused by fluid loss from diarrhea. It involves giving the child oral rehydration solutions containing electrolytes and fluids to replace those lost through diarrhea.
Choice B rationale:
Providing a diet high in sodium is not recommended for a child with shigella. Shigella is associated with diarrhea and gastrointestinal symptoms, and a high-sodium diet can worsen fluid imbalances and dehydration.
Choice C rationale:
Shigella is a bacterial infection, not a viral infection, so administering antiviral medication would not be effective or appropriate. Antiviral medications are used to treat viral infections, not bacterial ones like shigella.
Choice D rationale:
Giving antidiarrheal agents every 4 hours is not recommended for a child with shigella. Antidiarrheal agents can slow down the gastrointestinal tract and inhibit the body's natural mechanism for expelling harmful substances, such as bacteria. It's important to allow the body to eliminate the bacteria and toxins causing the infection through diarrhea, while simultaneously providing rehydration support.
Correct Answer is B
Explanation
Choice A rationale:
Implementing fluid restrictions is not recommended for a child with diabetic ketoacidosis (DKA). DKA is characterized by dehydration and electrolyte imbalances, and fluid replacement is a crucial aspect of its management. Restricting fluids could worsen dehydration and hinder the correction of metabolic imbalances.
Choice B rationale:
(Correct Choice) Monitoring vital signs every 8 hours is an important intervention for a school-age child with DKA. Vital signs, including heart rate, respiratory rate, blood pressure, and temperature, provide valuable information about the child's overall condition, fluid status, and response to treatment. More frequent monitoring might be necessary during the acute phase of DKA.
Choice C rationale:
Initiating continuous cardiac monitoring is not typically indicated for a school-age child with DKA. While DKA can have effects on the cardiovascular system, continuous cardiac monitoring is reserved for more critical situations where immediate changes in heart rhythm need to be detected.
Choice D rationale:
Administering subcutaneous insulin 30 minutes before meals is not appropriate for a child with DKA. In DKA management, insulin is typically administered intravenously to achieve more precise control over blood glucose levels. Subcutaneous insulin might not provide the rapid and consistent action needed to address the acute hyperglycemia and metabolic acidosis in DKA.
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