A nurse is planning care for a child who has varicella. Which of the following interventions should the nurse plan to include?
Provide the child with a warm blanket.
Assess the oral cavity for Koplik spots.
Administer aspirin for fever.
Initiate airborne precautions.
The Correct Answer is D
A. Providing a warm blanket can help alleviate discomfort associated with fever and chills, which are common symptoms of varicella.
B. Koplik spots are seen in measles, not varicella.
C. Aspirin administration is contraindicated in varicella due to the risk of Reye's syndrome. Acetaminophen or ibuprofen may be used for fever.
D. Varicella is spread through respiratory droplets, so standard precautions are typically sufficient. Airborne precautions are necessary to prevent transmission.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Examining the child for skin irritation at the cast edges is important to prevent complications but may not be the priority compared to monitoring for signs of impaired circulation or compartment syndrome.
B. Restricting the child's strenuous activities for 3 days is important for preventing damage to the cast, but it is not as urgent as monitoring for potential complications.
C. Monitoring for pallor or swelling in the child's affected hand is the priority to assess for impaired circulation or compartment syndrome, which are potential complications of cast application.
D. Using a hair dryer on a cool setting to relieve itching is a helpful tip but is not as urgent as monitoring for signs of impaired circulation.
Correct Answer is B
Explanation
A. No head lag when pulled to a sitting position is a normal finding at 4 months of age and does not require notification of the provider.
B. The Doll's eye reflex (also known as oculocephalic reflex) should be absent by 4 months of age. Its persistence could indicate neurological abnormalities and warrants further evaluation by the provider.
C. Presence of tears when crying is a normal physiological response and does not require notification of the provider.
D. Positive Babinski reflex is normal in infants under 2 years old and typically disappears by 12 to 24 months of age. It does not require immediate notification of the provider.
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