Exhibits here
The nurse is implementing the plan of care.
For each body system, click to specify the potential nursing intervention that would be appropriate for the care of the client. Each body system may support more than one potential nursing intervention. Each category must have at least one response option selected.
The Correct Answer is []
Immunological Administer antihistamine
The correct answer is to administer antihistamine. Antihistamines can help alleviate symptoms of an allergic reaction, such as itching, hives, and swelling, by blocking the effects of histamine
released during the allergic response.
Cardiovascular
Monitor vital signs continuously
The correct answer is to monitor vital signs continuously. Continuous monitoring of vital signs, including blood pressure, heart rate, and oxygen saturation, is essential to detect any changes in the client's cardiovascular status, especially after experiencing adverse reactions to medication.
Provide warmth
Providing warmth can help improve peripheral circulation and comfort for the client, especially if they are experiencing symptoms such as dizziness or feeling cold due to a drop in blood pressure.
Respiratory
Assess lung sounds
The correct answer is to assess lung sounds. Assessing lung sounds can help determine if the client is experiencing any respiratory distress or complications, such as wheezing or crackles, which may indicate a need for further intervention or respiratory support.
Chest x-ray
Ordering a chest x-ray can help evaluate the client's respiratory status, especially if there are concerns about potential complications such as pneumonia or pulmonary edema. It allows for the assessment of lung fields and can provide valuable information about the client's respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. 2+ pitting edema of the feet. While edema requires monitoring and may necessitate some adjustments in care, it does not directly impact the ability to provide a bed bath.
B. Pallor. Pallor indicates potential anemia or poor circulation but does not directly impact the provision of a bed bath.
C. Orthopnea. Orthopnea, difficulty breathing when lying flat, is critical to consider when planning a bed bath. The client may need to be positioned with the head elevated to facilitate breathing and ensure comfort during the bath.
D. Right-sided paralysis. Paralysis requires careful handling to prevent injury, but it is not as
immediately critical to the bathing process as orthopnea, which directly affects the client's ability to breathe comfortably.
Correct Answer is D
Explanation
- A: Providing a list of alternative activities may reduce fatigue, but it does not consider the child's interest in swimming, which can be therapeutic and enjoyable for children with Duchenne muscular dystrophy.
- B: While team sports can be good for socialization, they may not be suitable for a child with Duchenne muscular dystrophy due to the progressive muscle weakness associated with the condition, which could lead to increased risk of injury.
- C: At the age of 6, children are capable of understanding basic risks, and it is important to communicate with them appropriately rather than assuming they are too young. Moreover, swimming can be adapted to be safe for children with physical limitations.
- D: Swimming is an excellent activity for children with Duchenne muscular dystrophy because it is low-impact and can help maintain muscle strength and function. With proper supervision and precautions, the risks can be managed, making it a suitable activity for the child to continue.
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