The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?
Apply baby lotion to the skin twice daily.
Bathe the child daily with bath oil.
Allow the child to wear only 100% cotton clothing.
Keep the nails trimmed short.
The Correct Answer is D
Keeping the child's nails trimmed short helps minimize the risk of further skin damage and infection resulting from scratching. It reduces the likelihood of breaking the skin and causing bleeding. This preventive measure can help protect the child's skin and promote healing. It is important to combine nail trimming with other appropriate interventions for managing eczema, such as moisturizing the skin, avoiding irritants, and following the healthcare provider's recommendations for treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Following a pneumonectomy, it is important for the client to gradually resume normal activities and engage in social interactions. Encouraging family gatherings can provide emotional support, facilitate social connections, and help reduce feelings of isolation that the client may be experiencing.
While it is generally important for clients who have undergone a pneumonectomy to take precautions to reduce the risk of respiratory infections, such as avoiding crowded places and individuals with respiratory infections, completely avoiding social contact for several weeks is not necessary or realistic in most cases. It is essential to find a balance between protecting the client's health and promoting their emotional well-being and social integration.
Wearing a face mask during family events may not be necessary unless there is a specific concern about respiratory infections. The nurse can educate the client about the importance of good hand hygiene and avoiding close contact with individuals who are actively ill with respiratory infections.
Correct Answer is A
Explanation
Septic shock is a life-threatening condition characterized by a severe infection that leads to systemic inflammation, organ dysfunction, and low blood pressure. Maintaining strict intake and output monitoring is essential to assess the client's fluid balance and response to interventions. It allows the nurse to closely monitor the client's urine output, which is a crucial indicator of renal perfusion and overall organ function.
Monitoring urine output helps the nurse assess the adequacy of tissue perfusion and the client's response to fluid resuscitation. A decrease in urine output can be an early sign of worsening organ dysfunction and a need for further interventions.
While assessing the warmth of extremities is important for evaluating peripheral perfusion, maintaining strict intake and output monitoring takes priority as it provides more comprehensive information about the client's overall fluid status.
Raising the head of the bed 45 degrees (semi-Fowler's position) can help optimize respiratory function and reduce the risk of aspiration, but it is not the most important intervention in this case.
Monitoring blood glucose levels is important, as hyperglycemia can be associated with sepsis. However, in the context of septic shock, maintaining strict intake and output monitoring takes precedence as it directly assesses the client's fluid balance and response to interventions.
It's crucial to note that the management of septic shock requires a multidisciplinary approach, and other interventions, such as administering appropriate antibiotics, initiating fluid resuscitation, and addressing the underlying source of infection, should also be implemented in a timely manner.
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