A nurse is caring for a child who is suspected of having pertussis. The nurse should recognize that the pathophysiology of pertussis includes which of the following?
The infection mainly affects the nostrils.
The infection is viral in nature.
The toxins released by the bacteria attack epithelial cell cilia.
The lungs and airway become inflamed.
Secretions are produced and are challenging to expel.
Correct Answer : C,D,E
A. Pertussis primarily affects the respiratory tract rather than just the nostrils.
B. Pertussis is caused by the bacterium Bordetella pertussis, making it a bacterial infection, not viral.
C. The bacteria release toxins that damage the cilia of the epithelial cells in the respiratory tract, disrupting their function.
D. Inflammation occurs in the lungs and airway due to the infection, contributing to symptoms such as cough.
E. The infection leads to excessive secretions that are difficult to expel, resulting in the characteristic whooping cough associated with pertussis.
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Correct Answer is D
Explanation
A. While anxiety and withdrawal are concerning, they may not require immediate intervention compared to behaviors that pose risks to the child or others.
B. A stable child with a concerned parent may benefit from reassurance and support, but they do not require urgent intervention.
C. Stomach pain without an apparent cause should be assessed, but it may not be as urgent as aggressive behavior that can harm others.
D. A child exhibiting aggressive behavior poses a risk to themselves and others, necessitating immediate assessment and intervention to ensure safety and manage the behavior effectively.
Correct Answer is ["A","B","D","E"]
Explanation
A. It is important for the client to remain in bed for a specified time (typically 4 to 6 hours) to prevent complications such as bleeding at the catheter insertion site.
B. Checking peripheral pulses in the affected extremity is crucial for assessing circulation and identifying any potential complications, such as hematoma or occlusion.
C. High-Fowler's position is not typically appropriate immediately after cardiac catheterization; the client should remain flat or with limited elevation to reduce stress on the insertion site.
D. Keeping the hip and leg extended is important to prevent flexion at the site of catheter insertion, reducing the risk of bleeding or hematoma formation.
E. Measuring vital signs is essential after a procedure like cardiac catheterization to monitor for any changes that may indicate complications; however, the frequency is typically more frequent than every 4 hours initially.