,The nurse is planning care for the adolescent. Select the 5 interventions the nurse should
include.
A. Instruct the parent to ensure the pneumococcal vaccine is current.
B. Administer folic acid as prescribed.**
C. Monitor oxygen saturation continuously.**
D. Place the client on strict bed rest.
E. Apply cold compresses to the affected joints.**
F. Administer meperidine IV for pain.**
G. Restrict oral intake.
H. Give oral hydroxyurea.**
ANS: B C E F H
,2. Atopic dermatitis discharge teaching SATA
A. Occasional flare ups, mild detergent laundry, apply gloves, cut nails frequency,
apply emollients after bathing
Question
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?
Select all that apply.
A. "You should cut and file your child's fingernails frequently."**
B. "You should use a mild detergent for your child's laundry."**
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**
ANS: A B D F G
, 3. 6-week infant failure to thrive, tachypnea & tachycardia nursing actions
A. Admin digoxin, elevate HOB, CHF, Monitor respiratory & I/O
A nurse is caring for a 6-week-old infant.
History and Physical
Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as
expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb).
Parent reports for past 2 days infant is breathing faster during feedings and does not finish
feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent
states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation,
failure to thrive, and nutritional/fluid support.
Vital Signs
Admission:
Temperature 37.7° C (99.9° F) Heart rate 174/min while sleeping
Respiratory rate 72/min while sleeping
Assessment:
Admission:
Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation,
crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically. Skin:
Pallor, scalp is diaphoretic, lower extremities are cool to touch.
Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and
bounding in the upper extremities and weak bilateral pedal pulses are noted.
Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary
refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet.
include.
A. Instruct the parent to ensure the pneumococcal vaccine is current.
B. Administer folic acid as prescribed.**
C. Monitor oxygen saturation continuously.**
D. Place the client on strict bed rest.
E. Apply cold compresses to the affected joints.**
F. Administer meperidine IV for pain.**
G. Restrict oral intake.
H. Give oral hydroxyurea.**
ANS: B C E F H
,2. Atopic dermatitis discharge teaching SATA
A. Occasional flare ups, mild detergent laundry, apply gloves, cut nails frequency,
apply emollients after bathing
Question
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?
Select all that apply.
A. "You should cut and file your child's fingernails frequently."**
B. "You should use a mild detergent for your child's laundry."**
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**
ANS: A B D F G
, 3. 6-week infant failure to thrive, tachypnea & tachycardia nursing actions
A. Admin digoxin, elevate HOB, CHF, Monitor respiratory & I/O
A nurse is caring for a 6-week-old infant.
History and Physical
Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as
expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb).
Parent reports for past 2 days infant is breathing faster during feedings and does not finish
feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent
states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation,
failure to thrive, and nutritional/fluid support.
Vital Signs
Admission:
Temperature 37.7° C (99.9° F) Heart rate 174/min while sleeping
Respiratory rate 72/min while sleeping
Assessment:
Admission:
Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation,
crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically. Skin:
Pallor, scalp is diaphoretic, lower extremities are cool to touch.
Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and
bounding in the upper extremities and weak bilateral pedal pulses are noted.
Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary
refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet.
