A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?
Encourage the family to involve siblings when caring for the child.
Reinforce with the family that they should avoid discussing death with the child.
Collect vital signs every 2 hr as the child's condition deteriorates.
Perform passive range of motion to the child's extremities every 4 hr.
The Correct Answer is A
A. Encouraging the family to involve siblings in the care of the terminally ill child is important for fostering family support, allowing siblings to understand the situation, and promoting emotional bonding.
B. Avoiding discussions about death is not recommended. It is important to communicate with the child about death in an age-appropriate manner to help them understand and cope with the situation.
C. While monitoring vital signs is important, it is not the most therapeutic intervention in the final stages of terminal illness. Comfort care, including pain management and emotional support, takes priority.
D. Passive range of motion is not essential for a child in the final stages of terminal illness unless necessary for specific comfort or mobility needs. Care should focus on comfort measures rather than routine interventions.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. Barrel chest is not a typical finding in RSV. It is more commonly associated with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD) or cystic fibrosis.
B. Clubbing of the fingers is usually seen in chronic respiratory conditions like cystic fibrosis, but it is not a typical manifestation of RSV, which is usually acute.
C. Vesicles on the trunk are characteristic of viral infections such as chickenpox, not RSV. RSV primarily affects the respiratory system, causing symptoms like wheezing and coughing.
D. Rhinorrhea, or a runny nose, is a common early symptom of RSV. RSV often starts with cold-like symptoms, including nasal congestion, rhinorrhea, and cough, before progressing to more severe respiratory distress.
Correct Answer is C
Explanation
A. Massaging the injection site is not recommended, as it can cause irritation or tissue damage, especially after certain types of injections.
B. The dorsogluteal muscle is no longer recommended for vaccine administration due to the risk of injury to the sciatic nerve. The preferred site is the vastus lateralis or deltoid muscle.
C. It is essential to ensure that the guardian has signed an informed consent form prior to administering the vaccine. This confirms that the guardian is aware of the vaccine's benefits and potential risks.
D. Aspirating for blood return before administering vaccines is no longer recommended or necessary for intramuscular injections.
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