After administering varicella vaccine to a five-year-old child, which instruction should the nurse provide the child's parent?
Apply a cool pack to the injection site to reduce discomfort.
Any level of fever is serious and should be reported right away.
Chewable children's aspirin will help prevent inflammation.
Keep the child home from daycare for the next two days.
The Correct Answer is A
Choice A reason: Applying a cool pack to the injection site is a simple and effective way to reduce discomfort after receiving the varicella vaccine. The cool pack can help numb the pain, decrease swelling, and prevent bruising. The nurse should instruct the parent to apply the cool pack for 10 to 15 minutes at a time, several times a day, as needed.
Choice B reason: Any level of fever is not serious and does not need to be reported right away. Fever is a common side effect of the varicella vaccine and usually lasts for 1 to 2 days. Fever is a sign that the body is developing immunity against the chickenpox virus. The nurse should instruct the parent to monitor the child's temperature and give them acetaminophen or ibuprofen to lower the fever, if necessary. The nurse should also advise the parent to call the health care provider if the fever is higher than 102°F (38.9°C) or lasts longer than 3 days.
Choice C reason: Chewable children's aspirin will not help prevent inflammation and may cause serious harm. Aspirin is not recommended for children under 18 years of age who have viral infections, such as chickenpox, because it can increase the risk of Reye's syndrome, a rare but potentially fatal condition that affects the brain and liver. The nurse should instruct the parent to avoid giving the child aspirin or any products that contain aspirin, such as bismuth subsalicylate.
Choice D reason: Keeping the child home from daycare for the next two days is not necessary and may be inconvenient. The varicella vaccine is very effective at preventing chickenpox and does not pose a risk of spreading the virus to others. The nurse should instruct the parent to resume the child's normal activities, unless they have other symptoms that warrant staying home, such as rash, vomiting, or diarrhea.
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Correct Answer is C
Explanation
Choice A reason: Encouraging the parents to rest when possible is not the first intervention that the nurse should instruct the mother to implement. While it is important for the parents to take care of themselves, the priority is to address the child's needs and comfort.
Choice B reason: Making a list of foods that the child likes is not the first intervention that the nurse should instruct the mother to implement. While it is important to maintain the child's nutrition and hydration, the child may not have an appetite due to the fever and inflammation caused by Kawasaki disease.
Choice C reason: Placing the child in a quiet environment is the first intervention that the nurse should instruct the mother to implement. This is because Kawasaki disease causes irritability and sensitivity to light and sound in the child. A quiet environment can help reduce the child's stress and discomfort.
Choice D reason: Applying lotion to hands and feet is not the first intervention that the nurse should instruct the mother to implement. While it is important to moisturize the skin and prevent cracking and infection, the lotion may not relieve the child's pain and inflammation.
Correct Answer is B
Explanation
Choice A reason: Chickenpox is not the most significant illness that may be associated with acute rheumatic fever. Chickenpox is a viral infection that causes an itchy rash and blisters. It is not caused by group A streptococcus (GAS) bacteria, which are the main trigger of acute rheumatic fever.
Choice B reason: Sore throat is the most significant illness that may be associated with acute rheumatic fever. Sore throat can be caused by GAS bacteria, which can also cause strep throat or scarlet fever. If these infections are not properly treated with antibiotics, they can lead to acute rheumatic fever, which is an inflammatory disease that can affect the heart, joints, skin, and brain.
Choice C reason: Mumps is not the most significant illness that may be associated with acute rheumatic fever. Mumps is a viral infection that causes swelling of the salivary glands. It is not caused by GAS bacteria, which are the main trigger of acute rheumatic fever.
Choice D reason: Influenza is not the most significant illness that may be associated with acute rheumatic fever. Influenza is a viral infection that causes fever, cough, sore throat, and muscle aches. It is not caused by GAS bacteria, which are the main trigger of acute rheumatic fever.
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