1.
The mother of a 3-week-old tells the nurse she is residing in a homeless shelter and
is concerned about his mild cough, poor appetite, low-grade fever, weight loss, and
fussiness over the last 2 weeks. Which nursin
...
1.
The mother of a 3-week-old tells the nurse she is residing in a homeless shelter and
is concerned about his mild cough, poor appetite, low-grade fever, weight loss, and
fussiness over the last 2 weeks. Which nursing intervention would be the nurse's
highest priority?
1. Weigh the baby to have an accurate weight using standard precautions.
2. Reassure the mother that the baby may only have a cold, which can last a few
weeks.
3. Immediately initiate droplet face-mask precautions, and isolate the infant.
4. Take a rectal temperature while completing the assessment using standard
precautions.
Rationale:
1. Weighing the child would be important but not the priority when concerned about an
infectious cause. Initiating droplet precautions to prevent infecting others would be a
priority, then weighing the infant.
2. The symptoms are not suggestive of a cold but something more serious. Infants do
not usually lose weight, nor are they irritable with a simple cold.
3.
Children with tuberculosis may have a history of living in a crowded home or
could be homeless. Other symptoms may include a cough, cold symptoms, low-grade
fever, irritability, poor appetite, and exposure to a person with tuberculosis. Initiation of
droplet precautions and isolation of the infant would be warranted in this situation.
4. Taking the infant's temperature is important, but initiating droplet precautions would
be the priority.
TEST-TAKING HINT:
The test taker should be
highly suspicious of tuberculosis given the family and patient history. Health-care
personnel need to be vigilant to contain and prevent further spread of communicable
diseases. This child could have meningitis, which would also require isolation and
respiratory precautions.
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