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: Draw sheet:
A draw sheet can be used to assist in repositioning a patient, but it is not the most effective method for turning a client who has undergone spinal fusion. The primary concern is to maintain spinal alignment, which is best achieved through the log roll technique.
Choice B reason: Log roll:
The log roll technique is the preferred method for turning patients who have had spinal surgery. This technique involves moving the patient as a single unit, keeping the spine in alignment to prevent any twisting or bending that could disrupt the surgical site. It is especially important for obese patients to ensure that the spine remains stable during movement.
Choice C reason: Sliding board:
A sliding board is typically used to assist with transfers from one surface to another, such as from a bed to a wheelchair. It is not suitable for turning a patient in bed, particularly one who has had spinal surgery.
Choice D reason: Hoyer lift:
A Hoyer lift is a mechanical device used to lift and transfer patients who are unable to move themselves. While it can be useful for transferring patients, it is not designed for turning patients in bed and does not provide the necessary support to maintain spinal alignment during a turn.
Correct Answer is A
Explanation
Choice A: Flu-like symptoms and night sweats
The initial symptoms of HIV infection often resemble those of the flu. These symptoms, known as acute retroviral syndrome (ARS) or primary HIV infection, typically occur within 2 to 4 weeks after the virus enters the body. Common symptoms include fever, chills, night sweats, muscle aches, sore throat, fatigue, swollen lymph nodes, and a rash. These symptoms are the body’s natural response to the virus and indicate that the immune system is reacting to the infection. Night sweats, in particular, are a common symptom during the early stages of HIV infection.
Choice B: Fungal and bacterial infections
Fungal and bacterial infections are more commonly associated with later stages of HIV infection, particularly when the immune system has been significantly weakened. As HIV progresses and the immune system deteriorates, individuals become more susceptible to opportunistic infections, which are infections that occur more frequently and are more severe in people with weakened immune systems. These infections are not typically seen in the initial stages of HIV infection.
Choice C: Pneumocystis lung infection
Pneumocystis pneumonia (PCP) is a serious infection that occurs in people with weakened immune systems, including those with advanced HIV/AIDS. It is caused by the fungus Pneumocystis jirovecii. PCP is not an initial symptom of HIV infection but rather a complication that can arise when the immune system is severely compromised. This infection is more indicative of the later stages of HIV, particularly when the CD4 cell count drops significantly.
Choice D: Kaposi’s sarcoma
Kaposi’s sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. It is caused by the human herpesvirus 8 (HHV-8) and is commonly associated with advanced HIV infection or AIDS. Kaposi’s sarcoma presents as purple, red, or brown blotches or tumors on the skin and can also affect internal organs. This condition is not an initial symptom of HIV infection but rather a manifestation of severe immune system damage in the later stages of the disease.