A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take?
Assess the rest of the child's body for a rash.
Refer the family to child protective services.
Question the parents about how the marks occurred on the child's cheeks.
Obtain the child's temperature.
The Correct Answer is A
Choice A reason: Assess the rest of the child's body for a rash.
The child's red marks across the cheeks are characteristic of fifth disease (also known as erythema infectiosum). Fifth disease is caused by parvovirus B19 and typically presents with a bright red rash on the cheeks, often referred to as "slapped cheek" appearance. The rash may eventually spread to other areas of the body, including the arms, trunk, thighs, and buttocks. It is usually mild and self-limiting.
Choice B reason: This option is not appropriate for a rash caused by fifth disease. There is no indication of child abuse or neglect.
Choice C reason: The rash is due to a viral infection and not related to trauma or injury. Questioning the parents is unnecessary.
Choice D reason: While assessing the child's temperature is important in general nursing care, it is not specifically related to the red marks on the cheeks in this case.
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Correct Answer is A
Explanation
Choice A reason: Assess the rest of the child's body for a rash.
The child's red marks across the cheeks are characteristic of fifth disease (also known as erythema infectiosum). Fifth disease is caused by parvovirus B19 and typically presents with a bright red rash on the cheeks, often referred to as "slapped cheek" appearance. The rash may eventually spread to other areas of the body, including the arms, trunk, thighs, and buttocks. It is usually mild and self-limiting.
Choice B reason: This option is not appropriate for a rash caused by fifth disease. There is no indication of child abuse or neglect.
Choice C reason: The rash is due to a viral infection and not related to trauma or injury. Questioning the parents is unnecessary.
Choice D reason: While assessing the child's temperature is important in general nursing care, it is not specifically related to the red marks on the cheeks in this case.
Correct Answer is D
Explanation
Choice A reason: Tetany is not a typical finding in an infant who is dehydrated. Tetany is a condition where the muscles contract involuntarily and cause spasms or cramps. It is usually caused by low calcium levels or alkalosis, not dehydration.
Choice B reason: Slow, bounding pulse is not a typical finding in an infant who is dehydrated. A slow, bounding pulse may indicate increased intracranial pressure or heart failure, not dehydration. A fast, weak pulse is more likely to occur in an infant who is dehydrated.
Choice C reason: Decreased temperature is not a typical finding in an infant who is dehydrated. A decreased temperature may indicate hypothermia or sepsis, not dehydration. A normal or slightly elevated temperature is more likely to occur in an infant who is dehydrated.
Choice D reason: Irritability is a typical finding in an infant who is dehydrated. Irritability indicates that the infant is uncomfortable and thirsty. It may also be a sign of cerebral dehydration, which can affect the infant's mental status and behavior.
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