A nurse is caring for a school-age child who has acute otitis media and a new prescription for clindamycin. Which of the following findings indicates the child is experiencing an allergic reaction to the medication?
Urticaria.
Conjunctivitis.
Temperature 38°C (100.4°F).
Cool extremities.
The Correct Answer is A
Choice A rationale:
Urticaria, commonly known as hives, is a skin rash characterized by raised, red, and itchy welts that can vary in size and shape. It is a classic manifestation of an allergic reaction. Allergic reactions can occur in response to medications like clindamycin. Urticaria is a result of histamine release and can range from mild to severe, with itching being a prominent symptom. The appearance of urticaria in a child taking clindamycin suggests a potential allergic reaction to the medication.
Choice B rationale:
Conjunctivitis, or pink eye, is inflammation of the conjunctiva, the clear membrane that covers the white part of the eye and lines the inner surface of the eyelids. While conjunctivitis can be associated with allergies, it is not a typical sign of an allergic reaction to clindamycin. Conjunctivitis is more commonly associated with eye irritation, redness, and discharge.
Choice C rationale:
A temperature of 38°C (100.4°F) alone is not a definitive sign of an allergic reaction to medication. Fever can be caused by a variety of factors, including infections, inflammatory processes, and other non-allergic reactions. While fever can be a symptom of an allergic reaction in some cases, it is not as specific as urticaria in indicating an allergic response.
Choice D rationale:
Cool extremities are not a classic sign of an allergic reaction to medication. Allergic reactions typically involve skin manifestations like hives, itching, and redness. Cool extremities might suggest poor peripheral circulation or decreased blood flow to the extremities, but they are not directly indicative of an allergic reaction to clindamycin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale:
Headache is an expected finding in a school-age child with bacterial meningitis. Bacterial meningitis is an inflammation of the meninges, and the membranes surrounding the brain and spinal cord, often caused by bacteria. The inflammatory process can lead to increased intracranial pressure, which commonly presents as a headache. This headache is often severe and can be accompanied by other symptoms like fever, irritability, and sensitivity to light.
Choice B rationale:
A negative Kernig sign is a possible finding in a school-age child with bacterial meningitis. Kernig sign is a clinical test performed to assess for meningitis. A positive Kernig sign is characterized by resistance and pain in extending the knee when the hip is flexed at a 90-degree angle. However, a negative Kernig sign does not rule out meningitis, as it might not always be present.
Choice C rationale:
Vomiting is an expected finding in a school-age child with bacterial meningitis. The increase in intracranial pressure due to inflammation of the meninges can lead to nausea and vomiting. The vomiting is often projectile and may not be relieved by eating or drinking.
Choice D rationale:
Seizures are an expected finding in a school-age child with bacterial meningitis. The inflammation of the brain and meninges can irritate the brain tissue and trigger seizures. Seizures in the context of bacterial meningitis might be generalized or focal in nature.
Choice E rationale:
Tinnitus (ringing in the ears) is not a typical finding associated with bacterial meningitis. The main symptoms of bacterial meningitis are related to the central nervous system and meningeal irritation, such as headache, fever, neck stiffness, and neurological changes. Tinnitus is not a common manifestation of bacterial meningitis and is not part of the typical clinical picture.
Correct Answer is ["A"]
Explanation
It is essential for the nurse to stay with the client in this situation. The client's presentation indicates manic behavior, which can be associated with bipolar disorder. Manic episodes can lead to increased energy levels, decreased need for sleep, agitation, and impulsivity. The client's refusal to sit down, pacing, and becoming agitated when asked questions all indicate potential risk to themselves or others. Staying with the client ensures their safety and the safety of others in the environment. The nurse can provide verbal support, prevent potential harm, and de-escalate the situation if needed.
Placing the client in a room close to the nurses' station might be helpful for monitoring and quick assistance, but it doesn't directly address the client's immediate agitation and need for supervision. The priority in this scenario is to ensure the client's safety, which can be achieved by staying with them.
Offering the client a caffeinated beverage is not appropriate in this situation. Caffeine can exacerbate agitation and restlessness, potentially worsening the client's symptoms. It's important to provide a calm and supportive environment instead.
Weighing the client daily is not relevant to the current situation. The client's agitation and need for supervision take precedence over routine assessments like daily weight measurement.
Offering the client finger foods is also not appropriate in this situation. The client's behavior and presentation suggest a manic episode, and their agitation indicates that they are not in a state to engage in eating. Ensuring safety and providing emotional support are the immediate priorities.
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