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A nurse is reviewing discharge instructions with a client who has pruritus following treatment for scabies. Which of the following instructions should the nurse include?
- A. Take a hot shower daily to relieve itching.
- B. Wear loose fitting clothing while you are experiencing itching.
- C. Add fabric softener to linens when they are washed.
- D. Use a soft bristle brush to gently rub the affected areas.
Correct Answer: B
Rationale: Take a hot shower daily to relieve itching.' This instruction is not recommended because hot water can exacerbate itching and worsen the condition. Hot showers can strip the skin of its natural oils, leading to further dryness and irritation, which may aggravate the itching associated with scabies. 'Wear loose fitting clothing while you are experiencing itching.' This instruction is appropriate because loose-fitting clothing can help minimize friction and irritation on the skin affected by scabies. Tight clothing can exacerbate itching and discomfort, so wearing loose clothing can provide relief and allow the skin to breathe. 'Add fabric softener to linens when they are washed.' This instruction is not recommended because fabric softeners may contain chemicals or fragrances that can irritate the skin, especially for someone with pruritus or scabies. It's best to use gentle, fragrance-free laundry detergent to wash linens and clothing to minimize potential irritation. 'Use a soft bristle brush to gently rub the affected areas.' This instruction is not recommended because using a brush, even if it has soft bristles, can further irritate the skin and potentially spread the scabies mites to other areas of the body. It's best to avoid any abrasive or vigorous rubbing of the affected areas and instead focus on gentle cleansing and moisturizing techniques.
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A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Place the child in a side-lying position.
- B. Restrain the child's arms.
- C. Elevate the child's legs on a pillow.
- D. Insert a padded tongue blade into the child's mouth.
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
- A. Place new linen on the client's bed every other day.
- B. Change gloves between sites when providing wound care to multiple wounds.
- C. Change the dressing on infected wounds first.
- D. Monitor vital signs every 4 hr.
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?
- A. Orange-tinged urine
- B. Hypertension
- C. Periorbital edema
- D. Polyuria
Correct Answer: C
Rationale: Orange-tinged urine - This manifestation is not typically associated with nephrotic syndrome. Orange-tinged urine may indicate other conditions such as dehydration, liver disease, or the presence of certain medications or foods. Hypertension - Hypertension is not a common manifestation of nephrotic syndrome. However, it can occur in some cases due to the retention of sodium and water, which can lead to fluid overload and increased blood pressure. Periorbital edema - This is a classic manifestation of nephrotic syndrome. Periorbital edema, or swelling around the eyes, is often one of the initial signs observed in children with nephrotic syndrome due to the loss of protein in the urine, leading to fluid accumulation in the tissues. Polyuria - Polyuria, or increased urine output, is not typically associated with nephrotic syndrome. Instead, children with nephrotic syndrome may experience oliguria or normal urine output, depending on the severity of renal involvement and fluid balance.
Which of the following activities are appropriate for a child who is recovering from orchiopexy?
- A. Baseball games
- B. Running around the playground
- C. Horseback riding
- D. Puzzle games
Correct Answer: D
Rationale: Baseball games: Participating in baseball games may involve running, jumping, and sudden movements that could potentially strain the surgical area or cause discomfort. It's best to avoid strenuous physical activities like baseball until the child has fully recovered from orchiopexy. Running around the playground: Running around the playground may also involve vigorous physical activity that could potentially affect the surgical site. It's advisable to limit activities that involve running or jumping until the child's healthcare provider gives clearance. Horseback riding: Horseback riding involves sitting on a horse and may put pressure on the groin area, where the surgical site is located. It's generally recommended to avoid activities like horseback riding until the child has fully healed from orchiopexy. Puzzle games: Puzzle games are typically low-impact activities that do not involve physical exertion or strain on the surgical area. Engaging in quiet, seated activities like puzzle games can be suitable for a child who is recovering from orchiopexy and may help keep them entertained during the recovery period.
A nurse is caring for a 6-week-old infant admitted to the pediatric unit for evaluation of a suspected pyloric stenosis. Which of the following findings should the nurse expect?
- A. Projectile vomiting
- B. Metabolic acidosis
- C. Effortless regurgitation
- D. Distended abdomen
Correct Answer: A
Rationale: Projectile vomiting is a classic symptom of pyloric stenosis in infants. It typically occurs within 30 minutes of feeding and is forceful, often projecting several feet away from the infant. This occurs due to the obstruction at the pyloric sphincter, leading to the stomach forcefully emptying its contents. Metabolic acidosis is not a typical finding associated with pyloric stenosis. Pyloric stenosis leads to vomiting, which can result in dehydration and electrolyte imbalances, but it typically does not cause metabolic acidosis directly. Effortless regurgitation is not a characteristic finding of pyloric stenosis. In pyloric stenosis, vomiting is forceful and projectile, rather than a passive regurgitation of stomach contents. A distended abdomen can be a finding in pyloric stenosis. The obstruction at the pyloric sphincter can lead to gastric retention, causing the stomach to become distended over time. However, it's important to note that not all infants with pyloric stenosis will present with a visibly distended abdomen.