The clinic nurse receives a call from a parent of a 10-year-old who reports that their child just returned from summer camp and has developed an expanding circular red rash on the arm. The parent asks the nurse which over-the-counter (OTC) product is safe to use. How should the nurse respond?
Encourage the parent to come to the clinic if the child develops a fever.
Instruct the parent to apply an antihistamine ointment for one week.
Offer reassurance that OTC corticosteroid creams are safe and effective.
Explain the need for the child to have an immediate medical evaluation.
The Correct Answer is D
Choice A reason: Encouraging the parent to come to the clinic if the child develops a fever is not the best response that the nurse can give. This is because a fever may indicate a serious infection, such as Lyme disease, that requires prompt treatment. The nurse should not wait for the child to develop a fever before advising the parent to seek medical attention.
Choice B reason: Instructing the parent to apply an antihistamine ointment for one week is not the best response that the nurse can give. This is because an antihistamine ointment may not be effective for a fungal infection, such as ringworm, or a bacterial infection, such as Lyme disease, that may cause a circular rash. The nurse should not recommend any OTC product without knowing the exact cause of the rash.
Choice C reason: Offering reassurance that OTC corticosteroid creams are safe and effective is not the best response that the nurse can give. This is because corticosteroid creams may worsen a fungal infection, such as ringworm, or mask the symptoms of a bacterial infection, such as Lyme disease, that may cause a circular rash. The nurse should not recommend any OTC product without knowing the exact cause of the rash.
Choice D reason: Explaining the need for the child to have an immediate medical evaluation is the best response that the nurse can give. This is because a circular rash can be a sign of a serious condition, such as Lyme disease, that requires urgent diagnosis and treatment. The nurse should inform the parent that the rash may not be ringworm, as many people assume, and that it may be caused by a tick bite or another factor. The nurse should also advise the parent to avoid touching or scratching the rash and to keep it clean and dry until the child sees a doctor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The lumen of the aorta reduces the volume of blood flow to the lower extremities is the correct pathophysiologic mechanism that supports the findings. This is because coarctation of the aorta is a congenital condition that causes a narrowing of the aorta, usually near the ductus arteriosus. This results in increased resistance to blood flow from the heart to the lower body, leading to higher blood pressure and stronger pulses in the upper extremities and lower blood pressure and weaker pulses in the lower extremities.
Choice B reason: The aortic semilunar valve obstructs blood flow into the systemic circulation is not the correct pathophysiologic mechanism that supports the findings. This is because the aortic semilunar valve is located at the base of the aorta and prevents blood from flowing back into the left ventricle. If the valve is obstructed, it would cause aortic stenosis, which is a different condition from coarctation of the aorta. Aortic stenosis would cause symptoms such as chest pain, shortness of breath, and fainting.
Choice C reason: The pulmonic valve prevents adequate blood volume into the pulmonary circulation is not the correct pathophysiologic mechanism that supports the findings. This is because the pulmonic valve is located at the base of the pulmonary artery and prevents blood from flowing back into the right ventricle. If the valve is obstructed, it would cause pulmonic stenosis, which is a different condition from coarctation of the aorta. Pulmonic stenosis would cause symptoms such as cyanosis, fatigue, and heart murmur.
Choice D reason: An opening in the atrial septum causes a murmur due to a turbulent left to right shunt is not the correct pathophysiologic mechanism that supports the findings. This is because an opening in the atrial septum is a defect in the wall that separates the two upper chambers of the heart. It would cause a condition called atrial septal defect, which is different from coarctation of the aorta. Atrial septal defect would cause symptoms such as difficulty breathing, frequent respiratory infections, and heart palpitations.
Correct Answer is D
Explanation
Choice A reason: The ability to crawl is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes progressive loss of motor skills, so the infant may not be able to crawl or may have regressed from crawling. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice B reason: The eyes with cherry-red spot are not the most important assessment for the nurse to obtain. Tay-Sachs disease causes accumulation of gangliosides in the retina, which results in a cherry-red spot in the center of the macula. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice C reason: The difficulty with swallowing is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes muscle weakness and spasticity, which may affect the infant's ability to swallow. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice D reason: The exaggerated startle reaction is the most important assessment for the nurse to obtain. Tay-Sachs disease causes increased sensitivity to sound and touch, which results in an exaggerated startle reaction. This is a specific sign of the disease and indicates the severity of the condition. The exaggerated startle reaction may also trigger seizures, which can be life-threatening. The nurse should monitor the infant's vital signs, seizure activity, and neurological status closely.
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