A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?
Initiate contact precautions.
Initiate standard precautions.
Initiate airborne precautions.
Initiate droplet precautions.
The Correct Answer is D
Choice A: Contact precautions are not necessary for a child who has mumps, as mumps is not transmitted by direct or indirect contact with the infected person or their environment. Contact precautions are used for infections that are spread by contact with skin, wounds, body fluids, or contaminated surfaces.
Choice B: Standard precautions are always used for any patient care, regardless of their diagnosis or infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe injection practices, and proper disposal of waste and sharps. However, standard precautions alone are not sufficient for a child who has mumps, as mumps are transmitted by respiratory droplets.
Choice C: Airborne precautions are not necessary for a child who has mumps, as mumps are not transmitted by small particles that remain suspended in the air and can be inhaled by others. Airborne precautions are used for infections that are spread by airborne transmission, such as tuberculosis, measles, or chickenpox.
Choice D: Droplet precautions are required for a child who has mumps, as mumps are transmitted by large respiratory droplets that are expelled when the infected person coughs, sneezes, or talks. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorts with other patients with the same infection, and limiting visitors and staff who are susceptible to the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: A. Tugging on the affected ear lobe.
Choice A reason:
Tugging on the affected ear lobe is a common sign of discomfort in children with otitis media. This behavior indicates that the child is experiencing pain or pressure in the ear, which is a typical symptom of this condition. Children often cannot verbalize their discomfort, so they may tug or pull at their ears to express their pain.
Choice B reason:
Erythema and edema of the affected ear are more indicative of otitis externa (swimmer's ear) rather than otitis media. Otitis media involves inflammation and infection of the middle ear, which is not typically visible externally. The primary signs of otitis media are observed through otoscopic examination, showing a bulging or erythematous tympanic membrane.
Choice C reason:
Pain when manipulating the affected ear lobe is also more characteristic of otitis externa. In otitis media, the pain is usually deeper within the ear and not exacerbated by touching the outer ear. The pain in otitis media is due to the pressure and inflammation in the middle ear space.
Choice D reason:
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum due to the infection. Clear drainage is more commonly associated with conditions like otitis externa or a perforated eardrum without infection.
Correct Answer is B
Explanation
Choice A: The Oucher pain scale is not suitable for a 6-month-old infant, as it is designed for children aged 3 to 13 years who can point to pictures of faces that match their pain level. A 6-month-old infant cannot communicate verbally or point to pictures.
Choice B: The FLACC pain scale is suitable for a 6-month-old infant, as it is designed for infants and children aged 2 months to 7 years who cannot verbalize their pain. The FLACC pain scale assesses five behavioral indicators of pain: face, legs, activity, cry, and consolability. Each indicator is scored from 0 to 2 based on the observation of the nurse. The total score ranges from 0 to 10, with higher scores indicating more pain.
Choice C: The FACES pain scale is not suitable for a 6-month-old infant, as it is designed for children aged 3 years and older who can select a face that matches their pain level. A 6-month-old infant cannot communicate verbally or select a face.
Choice D: The Visual Analog Scale (VAS) is not suitable for a 6-month-old infant, as it is designed for adults and older children who can mark a point on a line that represents their pain level. A 6-month-old infant cannot communicate verbally or mark a point on a line.
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