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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. "Give the client several choices of foods for meals.": Providing multiple options can overwhelm a client with dementia and increase confusion or frustration. It is better to offer one or two simple choices to support decision-making without causing cognitive overload.

B. "Avoid making eye contact with the client.": Avoiding eye contact can appear dismissive or impersonal. Maintaining gentle eye contact helps establish trust, enhances communication, and can be grounding for clients who are cognitively impaired.

C. "Increase environmental stimuli”: A stimulating environment can lead to agitation or disorientation in clients with dementia. These clients benefit from calm, predictable surroundings with reduced noise, clutter, and distractions to support cognitive clarity.

D. "Label the door to the bathroom with a symbol.": Using clear labels or symbols helps orient clients with dementia and reduces confusion. Visual cues support recognition and promote independence in navigating their environment, especially with essential tasks like toileting.

A. Temperature B. WBC count C. Allergies D. Chest x-ray

Correct Answer is C

Explanation

Rationale:

• Temperature: An elevated temperature of 39.3° C is consistent with an active infection like pneumonia. This finding supports the need for antibiotic treatment and does not delay administration unless linked to an adverse drug reaction.

• WBC count: A WBC count of 16,000/mm³ indicates leukocytosis, which is expected in bacterial pneumonia. It confirms infection and the need for antibiotics, not a reason to withhold cefazolin.

• Allergies: The client has a documented allergy to penicillin, which is critical because cefazolin is a cephalosporin. Cephalosporins share a similar beta-lactam structure and can cross-react in clients with penicillin allergies, increasing the risk of anaphylaxis. Reporting this ensures safe prescribing and prevents a life-threatening hypersensitivity reaction.

• Chest x-ray: The left lower lobe density confirms pneumonia. This imaging supports the clinical decision to administer antibiotics and does not warrant withholding the prescribed medication.

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A nurse is caring for a toddler who has impetigo. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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