A nurse is reinforcing teaching with a client who is 12 hr postpartum and has an episiotomy. Which of the following instructions should the nurse include?
Cleanse the perineal area from back to front.
Wash the perineal area with povidone-iodine twice daily
Change the perineal pad with each void
"Wipe the perineal area with a soft cloth."
The Correct Answer is C
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.
Explanation:
When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.
Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.
Option c, offering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.
Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other fluids and prevent choking.
Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.
Correct Answer is B
Explanation
b. Perform passive range-of-motion exercises.
During a vaso-occlusive crisis in sickle-cell disease, blood flow to certain areas of the body may be restricted, leading to pain and tissue damage. Passive range-of-motion exercises can help promote blood circulation and prevent joint stiffness and further complications. These exercises involve gently moving the child's joints through their full range of motion without active participation from the child.
Explanation for the other options:
a. Limit fluid intake during the evening: Fluid intake is important in sickle-cell disease to prevent dehydration and maintain adequate blood flow. Restricting fluid intake during a vaso-occlusive crisis can further contribute to dehydration and may worsen the crisis. It is important to encourage fluid intake unless otherwise instructed by the healthcare provider.
c. Apply cold compresses to painful areas: Cold compresses are not recommended during a vaso-occlusive crisis in sickle-cell disease. Cold temperatures can cause vasoconstriction and further worsen the blood flow to affected areas, leading to increased pain and tissue damage. Warm compresses or warm packs may be used to promote vasodilation and provide pain relief.
d. Provide a low-protein diet: A low-protein diet is not specifically indicated in the plan of care for a vaso- occlusive crisis in sickle-cell disease. Adequate protein intake is important for overall nutritional needs and tissue repair. The focus of nutritional management in sickle-cell disease is usually on a well-balanced diet that includes adequate hydration and appropriate nutrient intake.
In summary, performing passive range-of-motion exercises is an appropriate intervention to include in the
plan of care for a school-age child experiencing a vaso-occlusive crisis in sickle-cell disease.
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