A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
Administer aspirin for fever.
Initiate airborne precautions,
Assess the oral cavity for Koplik spots.
Provide the child with a warm blanket
The Correct Answer is B
Choice A Reason:
Administer aspirin for fever is incorrect. Aspirin is contraindicated in children with varicella due to the risk of Reye's syndrome. Reye's syndrome is a rare but serious condition that can occur when aspirin is given to children with certain viral infections, including varicella.
Choice B Reason:
Initiate airborne precautions is correct. Varicella is transmitted via airborne droplets. Use airborne precautions (negative air-flow rooms) for patients with varicella. If negative air-flow rooms are not available, isolate patients in closed rooms with no contact with people without evidence of immunity
Choice C Reason:
Assess the oral cavity for Koplik spots is incorrect. Koplik spots are associated with measles, not varicella. Varicella typically presents with a rash that starts on the trunk and spreads to the rest of the body, along with other symptoms like fever and malaise.
Choice D Reason:
Varicella can cause fever and discomfort, and providing a warm blanket can offer comfort to the child, helping to alleviate chills or discomfort associated with fever. However, it is more important to initiate airborne precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Obtain written consent from the client is correct. In many jurisdictions, adolescents have the legal right to consent to STI testing and treatment without parental involvement or notification. Healthcare providers must adhere to confidentiality and privacy laws regarding adolescent health, particularly concerning sensitive issues like STI testing and treatment.
Choice B Reason:
Contact the client's parents to obtain phone consent is incorrect. Contacting the client's parents for consent might breach the adolescent's privacy and confidentiality, particularly in cases where they have the legal right to seek STI testing without parental involvement. In many jurisdictions, adolescents have the right to confidential healthcare services related to sexual health.
Choice C Reason:
Postpone the testing until the client's parents are present is incorrect. Delaying the testing until the client's parents are present could potentially compromise the adolescent's health. Confidentiality and timely access to healthcare services are critical, especially in cases concerning sexual health where prompt testing and treatment might be necessary.
Choice D Reason:
Request verbal consent from the social worker. Obtaining consent through a social worker might not follow proper healthcare protocols. Written consent from the adolescent themselves, if legally permissible, is typically required for such medical procedures, ensuring proper documentation and legal compliance.
Correct Answer is C
Explanation
Choice A Reason
Pulse rate 98/min: A pulse rate of 98 beats per minute is within the expected range for a 2-year-old child (normal range: 70-110 bpm). This finding is generally considered normal for this age and may not require immediate reporting.
Choice B Reason:
Temperature 37.2° C (99° F): A temperature of 37.2°C (99°F) is slightly elevated but is within the range of low-grade fever in children. However, at a well-child visit, this temperature might not be immediately alarming, especially if the child doesn't exhibit other signs of illness.
Choice C Reason:
Blood pressure 118/74 mm Hg:This reading is higher than the normal range for a 2-year-old child. High blood pressure in a young child should be evaluated further to determine the cause and need for intervention.
Choice D Reason:
Respiratory rate 26/min: The normal respiratory rate for a 2-year-old child typically ranges from 20 to 30 breaths per minute. A respiratory rate of 26 breaths per minute is within this range and may not warrant immediate concern.
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