The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent 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.

Keep the nails trimmed short.

Allow the child to wear only 100% cotton clothing.

Bathe the child daily with bath oil.

Answer and Explanation

The Correct Answer is B

A. While applying lotion can help keep the skin moisturized, it may not prevent scratching or bleeding from lesions.

B. Keeping the nails trimmed short is essential to prevent the child from scratching the lesions, which can lead to further irritation and potential infection. Short nails reduce the risk of breaking the skin and causing bleeding.

C. While cotton clothing is less irritating and may help manage eczema, ensuring that the child does not scratch the lesions is more critical in this scenario.

D. Daily baths can be beneficial, but they should not be done excessively as they can further dry the skin. Bath oils may help, but they do not directly address the issue of scratching.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Client is awake and following commands: Unrelated: This finding indicates the client's level of consciousness and responsiveness, which is not directly related to the effects of furosemide. While improving fluid status can contribute to overall well-being, this finding can be influenced by various factors unrelated to the medication.

Blood pressure 122/85 mm Hg: Therapeutic: The decrease in blood pressure indicates a positive therapeutic effect of furosemide, which is a diuretic used to reduce fluid overload and lower blood pressure in patients with heart failure. The improvement from 142/99 mm Hg to 122/85 mm Hg suggests successful fluid management.

Prothrombin time/international normalized ratio: Unrelated: This laboratory finding does not directly correlate with the administration of furosemide. It is more relevant to the patient’s anticoagulation therapy (warfarin) and is monitored separately from diuretic therapy.

Potassium 3.1 mEq/L: Non-therapeutic: This finding represents a non-therapeutic side effect of furosemide. Furosemide can cause hypokalemia (low potassium levels) due to increased urinary potassium excretion. A potassium level of 3.1 mEq/L is concerning and requires monitoring and possible potassium supplementation.

Clear breath sounds: Therapeutic: The presence of clear breath sounds indicates improved lung function and resolution of pulmonary congestion, which is a therapeutic outcome of effective diuretic therapy like furosemide. The reduction in edema and fluid overload can lead to better oxygenation and breathing efficiency.

A. Abdominal cramps. B. Diarrhea and flatulence. C. Muscle pain. D. Altered taste.

Correct Answer is C

Explanation

A. Abdominal cramps may occur with lovastatin but are generally not serious and do not require immediate intervention. They can often be managed with dietary changes or over-the-counter medications.

B. Diarrhea and flatulence are common side effects that, while uncomfortable, are not typically life-threatening and do not warrant urgent follow-up.

C. Muscle pain, or myopathy, is a significant side effect of lovastatin that can lead to serious complications such as rhabdomyolysis. This condition can cause kidney damage, so any report of muscle pain in a patient taking lovastatin requires immediate follow-up.

D. Altered taste is not a serious side effect and usually does not necessitate urgent intervention, although it may be bothersome to the patient.

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The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and orders. Click to mark whether the assessment finding represents a therapeutic result of the furosemide administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is C

Explanation

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