Author Question: Nursing care of the child with a snake bite involves assessment of the child for initial and ... (Read 103 times)

khang · **on:** Jun 28, 2018

Nursing care of the child with a snake bite involves assessment of the child for initial and progressive signs of envenomation. Which of the following is the priority nursing action at this time?

1. Assess the need for emergency breathing interventions.
2. Assess neurovascular status and vital signs.
3. Assess pain and the child's response to pain medication.
4. Measure the circumference of the extremity containing the bite every 2030 minutes.
5. Assess immunization status.

Question 2

The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help with the prevention of:

1. Poor circulation.
2. Hypertrophic scarring.
3. Pain.
4. Formation of thrombus in the burn area.

rachel · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

1
Rationale:
1. Emergency intervention for airway, breathing, and circulation take priority, and has a high probability of occurrence.
2. Vital signs and neurovascular status of the distal extremities should be monitored, but do not take priority over airway, breathing, and circulation.
3. Pain medication will need to be given and the response to the treatment monitored; however, this should not take priority over airway, breathing, and circulation.
4. In order to track progression in swelling and response to treatment, the extremity with the bite is measured every 2030 minutes. However, this does not take priority over airway, breathing, and circulation.
5. Immunization status is important information to obtain, but the more immediate need is for airway, breathing, and circulation.

Answer to Question 2

2
Rationale:
1. The Jobst pressure garments are used to prevent or minimize the development of hypertrophic scarring and contractures.
2. During the rehabilitation stage, Jobst stockings or pressure garments are used to reduce development of hypertrophic scarring and contractures.
3. The Jobst stockings or pressure garments do not prevent pain. They are used to prevent development of hypertrophic scarring and contractures.
4. The elastic pressure garments are used to prevent development of hypertrophic scarring and contractures. They do not prevent the formation of thrombus in the burn area.