For which of the following adverse effects should the nurse...

A nurse is assessing a school-age child who is receiving cefazolin.

For which of the following adverse effects should the nurse monitor?

A. Hypotension
B. Prolonged wound healing
C. Stevens-Johnson syndrome
D. Bradypnea

Correct Answer: C

Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.

A nurse is preparing to administer recommended immunizations to a 12-month-old infant who is up to date with the current schedule.

Which of the following immunizations should the nurse plan to administer?

A. Measles, mumps, and rubella (MMR)
B. Varicella (VAR)
C. Rotavirus (RV)
D. Herpes zoster
E. Human papillomavirus (HPV4)

Correct Answer: A,B

Rationale: The correct answer is A (MMR) and B (VAR). These immunizations are recommended for certain age groups to prevent measles, mumps, rubella, and varicella. MMR provides protection against three viral infections, while VAR protects against chickenpox. These vaccinations are part of the routine childhood immunization schedule to prevent the spread of these contagious diseases. Rotavirus (C) is given to infants to protect against a common cause of severe diarrhea, while Herpes zoster (D) and Human papillomavirus (E) are not typically administered by nurses in routine practice.

A nurse in the emergency department is preparing to discharge a 3-year- old child Nurses' Notes
The child's guardian states the child has been unable to sleep recently and has been very irritable. Guardian expresses concern about the child's atopic dermatitis worsening and the child scratching excessively, which results in the areas bleeding. Guardian states the child has a history of allergic rhinitis.
Assessment
Child is alert and responsive.
Respiratory rate even and nonlabored at rate of 24/min. No adventitious sounds auscultated. Heart rate 108/min
Generalized small clusters of reddish, scaly patches with lichenifications and depigmentation on the child's bilateral upper and lower extremities.

Which of the following statements should the nurse plan to include in the discharge instructions for the child's guardian?

A. You should cut and file your child's fingernails frequently.
B. Cystic fibrosis
C. You should apply a thick layer of pimecrolimus cream to your child's lesions.
D. Your child will experience occasional flare-ups of this condition.
E. Your child's condition is contagious when lesions are present.
F. You can apply gloves to your child's hands.
G. "You should apply emollients to your child's skin after bathing**

Correct Answer: A,B,D,F,G

Rationale: The correct answer includes multiple important statements for the discharge instructions.
A: Cutting and filing fingernails prevent scratching and potential skin damage.
B: Cystic fibrosis is relevant medical information for the child's care.
D: Informing about occasional flare-ups helps prepare the guardian.
F: Applying gloves prevents scratching and potential skin infection.
G: Emollients maintain skin hydration and prevent dryness. These instructions promote optimal care and management of the child's condition. Other choices are incorrect as they either provide irrelevant information (C), are not necessary for the child's care (E), or do not directly contribute to the child's well-being (B).

A nurse is providing teaching to the parents of a child who has impetigo.

Which of the following instructions should the nurse include in the teaching?

A. Apply bactericidal ointment to lesions.
B. Administer acyclovir PO two times per day.
C. Soak hairbrushes in boiling water for 10 min.
D. Seal soft toys in a plastic bag for 14 days.

Correct Answer: A

Rationale: The correct answer is A: Apply bactericidal ointment to lesions. This instruction is essential to prevent secondary bacterial infection in lesions caused by herpes zoster. The ointment will help to keep the lesions clean and prevent bacterial growth. Administering acyclovir helps treat the viral infection but does not prevent bacterial infection. Soaking hairbrushes and sealing soft toys are not directly related to preventing infection in the lesions. Overall, the focus should be on proper wound care to prevent complications.

A nurse is providing teaching to a 15-year-old adolescent about a medication used to treat a sexually transmitted infection.

Which of the following actions should the nurse take?

A. Inform the client to contact the pharmacy regarding any questions related to the medication.
B. Provide instructions to the client's parent with the client present.
C. Instruct the client's parents to write down the information that is being provided.
D. Ask how the client prefers to learn new information.

Correct Answer: D

Rationale: The correct answer is D: Ask how the client prefers to learn new information. This action is client-centered and promotes individualized care by understanding the client's preferred learning style. It helps tailor the teaching approach to best meet the client's needs, leading to improved understanding and compliance.
Choice A is incorrect because the nurse should provide medication information directly to the client instead of redirecting to the pharmacy.
Choice B is incorrect as it does not involve the client in the learning process, which is essential for effective education.
Choice C is incorrect as it focuses on the parents rather than the client, missing the opportunity to engage the client directly.
Overall, choice D stands out for its client-focused approach, making it the most appropriate action in this scenario.

A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder.

The nurse should teach the parents to take which of the following actions during a seizure?

A. Minimize movement of the limbs.
B. Clear the area of hard objects.
C. Place the child in a prone position.
D. Insert a tongue blade between the teeth.

Correct Answer: B

Rationale: The correct answer is B: Clear the area of hard objects. This action is crucial during a seizure to prevent injury. Hard objects can cause harm if the child hits them during convulsions. Minimizing limb movement is not recommended as it may lead to further injury. Placing the child in a prone position can obstruct breathing and should be avoided. Inserting a tongue blade can also cause harm and is not recommended. Clearing the area of hard objects is the most effective way to ensure safety during a seizure.