A 7-year-old child is diagnosed with scarlet fever. Which nu… | 마이메르시 MyMerci
Infectious Diseases
문제

A 7-year-old child is diagnosed with scarlet fever. Which nursing intervention should be implemented first?

A 6-year-old child presents to the pediatric unit with a high fever, sore throat, and a characteristic sandpaper-like rash covering the body. The child has been diagnosed with scarlet fever caused by group A streptococcus.
해설
Contact and droplet precautions are priority to prevent transmission of group A streptococcus. Other interventions (fever reduction, fluids, skin care) are supportive but secondary.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing action for a child with Scarlet fever. Scarlet fever is a bacterial infection caused by Group A Streptococcus (GAS), specifically strains that produce an erythrogenic toxin. The priority in managing any infectious disease, especially in a pediatric unit, is to prevent transmission to other patients, staff, and visitors. This aligns with the nursing process principle of Key Point! Safety First. Before providing supportive care, the nurse must secure the environment to stop the spread of the pathogen.

Answer Rationale: The correct answer is to Initiate contact precautions and droplet precautions. This is the first and most critical intervention. Key Point! Group A Streptococcus is transmitted primarily through respiratory droplets (from coughing, sneezing) and also through contact with respiratory secretions or contaminated objects. Implementing these Transmission-Based Precautions immediately upon diagnosis is a standard infection control protocol to protect public health and is a core responsibility of the nurse.

Distractor Analysis:
Watch out for confusion! While all other options are appropriate supportive measures, they are not the first priority.
Administer acetaminophen for fever reduction: Managing fever and discomfort is important for patient comfort and preventing complications like febrile seizures, but it does not address the immediate risk of disease transmission.
Encourage increased fluid intake: Hydration is crucial to prevent dehydration from fever and to thin respiratory secretions, but it is a supportive, not a priority, intervention.
Apply cool compresses to reduce skin irritation: Skin care for the characteristic "sandpaper" rash can provide comfort, but it is a comfort measure that comes after ensuring infection control.

Related Concepts: The principle of Airborne, Droplet, and Contact Precautions is fundamental. For NCLEX, know which diseases require which type. Scarlet fever requires Droplet + Contact until 24 hours after starting effective antibiotic therapy. Other key streptococcal infections include Streptococcal pharyngitis (strep throat) and Impetigo.
Concept SummaryPathogen: Group A Streptococcus (produces erythrogenic toxin). • Transmission: Respiratory droplets and direct contact. • Key Symptoms: "Strawberry" tongue, sandpaper-like rash, high fever, sore throat. • Priority Nursing Action: Immediate implementation of Droplet and Contact Precautions. • Medical Treatment: Antibiotics (Penicillin or Amoxicillin) to treat infection, prevent complications (e.g., rheumatic fever, glomerulonephritis), and reduce communicability.
Side-by-Side Comparison!
ConditionPrecaution TypeKey FeatureDuration of Precautions
Scarlet FeverDroplet + ContactSandpaper rash, strawberry tongueUntil 24 hrs after antibiotic start
Varicella (Chickenpox)Airborne + ContactVesicular rash in cropsUntil lesions are crusted
Pertussis (Whooping Cough)DropletParoxysmal cough with "whoop"Until 5 days of antibiotics
Measles (Rubeola)AirborneKoplik's spots, maculopapular rashUntil 4 days after rash appears

Anatomy, Physiology & Pharmacology PointsPathophysiology: The erythrogenic toxin causes capillary damage, leading to the characteristic diffuse erythematous rash and strawberry tongue (inflamed papillae). • Complication Alert: Untreated GAS infections can lead to Acute rheumatic fever (affecting heart valves) and Post-streptococcal glomerulonephritis (kidney inflammation). This is why prompt antibiotic treatment is crucial. • Pharmacology: First-line antibiotics are Penicillin or Amoxicillin. For penicillin-allergic patients, Azithromycin or Clindamycin may be used.
Memory TipsPrecaution Mnemonic for Scarlet Fever: "Scarlet needs Separation" (Droplet/Contact). Or remember "Droplets spread the Strep." • Symptoms: Think "Sandpaper Skin and Strawberry tongue" – the three S's of Scarlet fever.
High-Frequency NCLEX Topics NCLEX heavily tests infection control and safety. You will often be asked to identify the first or priority action. In any scenario involving a communicable disease, your first thought should be: "What precautions are needed to protect others?" This takes precedence over comfort measures or even some treatments.
Watch Out for Question Variations! • Instead of asking for the first intervention, the question might ask: "Which instruction is most important for the parents of a child with scarlet fever?" The answer would focus on completing the full course of antibiotics to prevent complications. • The question could present a child with symptoms and ask you to select the appropriate type of isolation room (e.g., a private room or a room with specific ventilation). • It might integrate medication administration: "The nurse is to administer the first dose of penicillin. What is the priority assessment before administration?" (Answer: Check for penicillin allergy).

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse receiving 6-year-old "Leo" in the pediatric emergency department. He is irritable, has a temperature of 39.5°C (103.1°F), a sore throat, and a bright red, blanching rash that feels like sandpaper on his trunk and extremities. His mother says it started with a fever two days ago. The physician diagnoses scarlet fever.

Nursing Intervention Strategy: 1. Immediate Action (Priority): Don appropriate PPE (gown, gloves, mask, eye protection). Place Leo in a private room or a room with another patient with the same infection. Place a "Droplet and Contact Precautions" sign on the door. Ensure masks are available for anyone entering. 2. Assessment: Perform a focused assessment while maintaining precautions. Assess airway, breathing, circulation. Examine the rash and oral cavity for "strawberry tongue." Obtain a throat culture if not already done. 3. Implementation of Supportive Care: • Fever Management: Administer antipyretics like acetaminophen as ordered. • Hydration: Encourage cool, non-acidic fluids (e.g., water, popsicles, apple juice) to soothe the throat and maintain hydration. Monitor for signs of dehydration (dry mucous membranes, decreased urine output). • Skin Care: Keep skin clean and dry. Use lukewarm baths and soft, non-irritating clothing. Trim the child's nails to prevent scratching. Calamine lotion or prescribed topical anti-itch medications may be used. • Medication Administration: Administer the first dose of antibiotic promptly. Educate the family on the importance of completing the entire course, even if symptoms improve. 4. Education & Evaluation: Teach parents about precaution duration (24 hours post-antibiotics). Instruct them to monitor for complications (e.g., dark urine, swollen joints, chest pain, shortness of breath). Evaluate for decreased fever, improved comfort, and understanding of discharge instructions.
Patient Safety and Precautions: • Precaution Duration: Maintain Droplet/Contact Precautions until the child has been on effective antibiotics for 24 hours and is afebrile. • Medication Caution: Always assess for drug allergies before administering the first dose of penicillin/amoxicillin. Observe for signs of anaphylaxis. • Complication Monitoring: Be vigilant for signs of Acute rheumatic fever (carditis, polyarthritis, chorea) or Glomerulonephritis (hematuria, edema, hypertension), which can appear 1-3 weeks after infection.
Nursing Procedure & Medication Flow Procedure for Initiating Droplet & Contact Precautions: 1. Identify the patient requiring precautions. 2. Place patient in a private room (preferred) or cohort with same infection. 3. Post clear signage on door/entry. 4. Don PPE (gown & gloves for Contact; mask & eye protection for Droplet) before entering room. 5. Remove PPE carefully inside the room before exiting to avoid contaminating the environment. 6. Perform hand hygiene with soap and water or alcohol-based gel immediately after PPE removal.
Medication Administration for Scarlet Fever: • Drug: Penicillin V Potassium (Oral). • Typical Pediatric Dose: 25-50 mg/kg/day divided BID-TID for 10 days. • Nursing Points: Give with food to minimize GI upset. Complete the full 10-day course is non-negotiable to prevent rheumatic fever. Assess for rash, diarrhea (possible C. diff), or signs of allergic reaction.
A Word from Your Senior Nurse "In the hustle of a busy unit, it's easy to jump straight to making the patient comfortable. But remember, your role as a nurse is also to be a protector of the community within the hospital. Isolating a contagious child isn't about stigma; it's about preventing an outbreak on your ward that could endanger other immunocompromised children. Always think: Safety first for ALL. Mastering this priority-setting mindset is what separates a good test-taker from an excellent, safe, and professional nurse."

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