A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
An infant who has pertussis and is receiving oxygen via nasal cannula.
A school-age child who has diabetes mellitus and requires blood glucose monitoring.
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
A toddler who has both arms in casts and needs to be fed his breakfast.
The Correct Answer is A
Choice A reason: An infant who has pertussis and is receiving oxygen via nasal cannula:
Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.
Choice B reason: A school-age child who has diabetes mellitus and requires blood glucose monitoring:
While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.
Choice C reason: An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions:
Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.
Choice D reason: A toddler who has both arms in casts and needs to be fed his breakfast:
While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.
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Correct Answer is B
Explanation
Choice A reason:
Wiping from back to front is incorrect and can lead to contamination of the urine sample with bacteria from the anal area. The correct method is to wipe from front to back to reduce the risk of contamination.
Choice B reason:
Urinating a small amount in the toilet before collecting the sample is the correct procedure for obtaining a midstream urine specimen. This helps to flush out any bacteria or contaminants from the urethra, ensuring that the sample collected is as clean as possible.
Choice C reason:
Letting the urine cool to room temperature before sending it to the lab is incorrect. Urine samples should be sent to the lab as soon as possible after collection to ensure accurate results. If there is a delay, the sample should be refrigerated.
Choice D reason:
It is generally recommended to avoid collecting a urine sample during menstruation, as menstrual blood can contaminate the sample and affect the test results.
Correct Answer is B
Explanation
Choice A reason: Akathisia:
Akathisia is characterized by a feeling of inner restlessness and an inability to stay still. It often manifests as constant movement, such as pacing or fidgeting. While akathisia is a common side effect of antipsychotic medications, it does not typically involve involuntary movements of the tongue and face.
Choice B reason: Tardive dyskinesia:
Tardive dyskinesia is a serious and often irreversible side effect of long-term antipsychotic use, including chlorpromazine. It is characterized by involuntary, repetitive movements, particularly of the face, tongue, and jaw. These movements can include lip smacking, tongue protrusion, and grimacing. This condition is a result of prolonged dopamine receptor blockade in the brain.
Choice C reason: Dystonia:
Dystonia involves sustained muscle contractions that cause twisting and repetitive movements or abnormal postures. It can affect any part of the body, including the neck, face, and limbs. While dystonia can be a side effect of antipsychotic medications, it typically presents as muscle spasms rather than the repetitive, involuntary movements seen in tardive dyskinesia.