A nurse is caring for a toddler who has impetigo. Which of the following actions should the nurse take?
Inform the caregiver that it is okay to use the same towels.
Request the provider to prescribe an antiviral medication.
Place the toddler on droplet precautions.
Prevent the toddler from scratching their skin by using elbow restraints.
The Correct Answer is D
Rationale:
A. Inform the caregiver that it is okay to use the same towels: Sharing towels can spread impetigo, which is a highly contagious bacterial skin infection. Families should be instructed to use separate towels, washcloths, and linens to reduce the risk of cross-contamination.
B. Request the provider to prescribe an antiviral medication: Impetigo is caused by bacteria such as Staphylococcus aureus or Streptococcus pyogenes, not viruses. Antibacterial agents, not antivirals, are the appropriate treatment for managing this condition.
C. Place the toddler on droplet precautions: Impetigo primarily spreads through direct contact with lesions or contaminated objects, not respiratory droplets. Standard precautions with contact isolation are typically used rather than droplet precautions.
D. Prevent the toddler from scratching their skin by using elbow restraints: Scratching can worsen impetigo lesions and lead to further bacterial spread or secondary infection. Using soft restraints like elbow splints can safely discourage scratching and promote healing while preventing the infection from spreading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Chromosomal abnormalities: Amniocentesis involves analyzing amniotic fluid to detect genetic and chromosomal disorders such as Down syndrome, trisomy 18, and neural tube defects. It is typically performed between 15 and 20 weeks gestation for diagnostic accuracy during this stage of fetal development.
B. Placental circulation: Assessment of placental blood flow and circulation is usually done via Doppler ultrasound, not amniocentesis. Amniocentesis does not evaluate the vascular function or perfusion status of the placenta.
C. Rh incompatibility: While amniocentesis may reveal fetal anemia due to Rh sensitization in rare cases, it is not the primary test used for diagnosing Rh incompatibility. Blood antibody screening and Doppler assessment of the middle cerebral artery are preferred for Rh-related concerns.
D. Fetal breathing movements: Fetal breathing is assessed through a biophysical profile or real-time ultrasound, not via amniotic fluid sampling. Amniocentesis does not provide information about the fetus’s respiratory activity or movement patterns.
Correct Answer is B
Explanation
Rationale:
A. Urinary retention: Urinary retention is a potential side effect of epidural anesthesia due to blockade of sacral nerves, not necessarily a sign of unrelieved pain. It may occur even if pain is well managed, especially with regional anesthetics affecting bladder function.
B. Restlessness: Restlessness is a common behavioral indicator of unrelieved pain. When verbal reporting is limited or unreliable, restlessness may reflect discomfort, agitation, or anxiety related to inadequate pain control following procedures such as epidural administration.
C. Difficulty swallowing: Difficulty swallowing is not associated with pain from a herniated disc or the effects of an epidural. It may instead suggest upper airway or neurologic issues and should prompt assessment for complications unrelated to pain control.
D. Constipation: Constipation is more commonly linked to opioid use or immobility rather than unrelieved pain. While discomfort may contribute, constipation alone does not reliably indicate the adequacy of pain relief in clients receiving an epidural.
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