A 4-year-old preschooler with varicella (chickenpox) is being cared for at home. The child's mother asks the nurse about appropriate care measures. Which nursing intervention should the nurse prioritize in the teaching plan?
1Apply topical antibiotics to all lesions to prevent secondary bacterial infection
2Give aspirin every 4 hours to reduce fever and discomfort
3Keep the child's fingernails short and clean to prevent scratching and secondary infection✓ 정답
4Encourage the child to return to school once the fever subsides
해설
Keeping fingernails short and clean prevents scratching, which reduces the risk of secondary bacterial infections and scarring. Other options are incorrect: topical antibiotics are not routine, aspirin is contraindicated, and returning to school too early can spread infection.
Core Nursing ExplanationKey Concept Analysis: This question tests the nurse's knowledge of home care for a child with Varicella (chickenpox), a highly contagious viral infection caused by the varicella-zoster virus (VZV). The core nursing priority is managing the primary symptom—the intensely itchy vesicular rash—to prevent complications, primarily secondary bacterial infection from scratching.
Answer Rationale: The correct answer is option 3. Key Point! The hallmark of varicella is a pruritic (itchy) rash that progresses from macules to papules, vesicles, and crusts. Scratching these lesions can break the skin barrier, introducing bacteria (commonly Staphylococcus aureus or Streptococcus pyogenes) and leading to cellulitis, impetigo, or even more serious systemic infections. Keeping fingernails short and clean is a simple, effective, and non-pharmacological intervention that directly addresses this risk and is a cornerstone of patient/family education.
Distractor Analysis:
Watch out for confusion! Option 1: Applying topical antibiotics to all lesions is not a standard, evidence-based practice. It promotes antibiotic overuse and resistance. Topical antibiotics (e.g., mupirocin) are only indicated if a secondary bacterial infection is already diagnosed.
Watch out for confusion! Option 2: Key Point! Giving aspirin to a child with a viral illness like varicella is absolutely contraindicated due to the risk of Reye's syndrome, a rare but severe condition causing acute encephalopathy and liver failure. For fever and discomfort, acetaminophen or ibuprofen are appropriate antipyretics/analgesics.
Watch out for confusion! Option 4: Returning to school once the fever subsides is incorrect. The standard isolation guideline for varicella is until all lesions have crusted over, which typically takes 5-7 days. The child remains contagious as long as new vesicles are forming, even without fever.
Related Concepts: Nursing care for varicella also includes symptomatic management: cool baths, calamine lotion for itch relief, antipyretics (avoiding aspirin), maintaining hydration, and airborne/contact isolation precautions. The varicella vaccine is the primary prevention.
Concept Summary
Topical antibiotics on all lesions (unnecessary, promotes resistance)
Infection Control
Isolate until all lesions crusted
Return when fever subsides (still contagious)
Anatomy, Physiology & Pharmacology Points
Pathophysiology: VZV invades via respiratory tract, replicates, causes viremia, and leads to the characteristic rash. Vesicles contain high concentrations of the virus.
Pharmacology: Antiviral therapy (e.g., acyclovir) may be used for high-risk patients (immunocompromised, adults) but is not routine for healthy children. Know the Reye's syndrome link between aspirin, viral illness, and mitochondrial damage in the liver/brain.
Memory Tips
CRUST is a MUST: Child can return when all lesions have Crusted.
No ASS for VIRUS: Never give ASpirin for a VIRal illnUS.
Scratch = Bad, Short Nails = Good: The primary nursing goal is to break the itch-scratch-infection cycle.
High-Frequency NCLEX Topics
This is a classic NCLEX question combining pediatric infectious disease management, patient/parent education, and safety (aspirin contraindication). Expect questions on: isolation precautions (airborne/contact), signs of complications (e.g., high fever returning after initial improvement may indicate secondary infection), and vaccine schedules (varicella vaccine at 12-15 months, booster at 4-6 years).
Watch Out for Question Variations!
Symptom Identification: "The mother reports the child has a fever and small, itchy blisters on the chest. The nurse should suspect..."
Priority Intervention: "A child with varicella develops a high fever and red, warm, swollen skin around a lesion. What is the nurse's priority action?" (Assess for/secondary bacterial infection).
Medication Administration: "The mother asks what she can give for fever. Which medication should the nurse recommend?" (Acetaminophen).
Discharge Teaching: "When teaching parents about home care, which statement by the parent indicates a need for further teaching?" (e.g., "I'll give him baby aspirin for the fever.").
Nursing Clinical Practice GuideClinical Scenario: You are a nurse in a pediatric clinic. Mrs. Jones brings in her 4-year-old son, Liam, who has a fever of 101.5°F (38.6°C) and a rash starting on his trunk. You note scattered red macules, papules, and clear vesicles. You diagnose varicella and provide home care instructions as Liam is otherwise healthy.
Nursing Intervention Strategy:
Assessment: Perform a full assessment. Document rash distribution (centripetal - starts on trunk/face, spreads outward), stage of lesions (macules, papules, vesicles, crusts), and presence of fever. Assess hydration status (skin turgor, mucous membranes, urine output).
Education & Planning:
Itch Management & Skin Care: Teach "The Rule of Short Nails." Demonstrate how to trim nails straight across and keep them clean. Suggest cotton mittens or socks on hands at night. Recommend cool oatmeal baths and patting skin dry. Apply calamine lotion to itchy spots.
Fever & Comfort: Instruct on proper dosing of acetaminophen or ibuprofen based on weight. Emphasize: "No aspirin, ibuprofen, or any product containing salicylates."
Infection Control: Teach strict isolation: Liam must stay home until ALL lesions are dried and crusted. This usually takes about 1 week. Siblings or household members without immunity should be assessed for vaccination.
Hydration & Nutrition: Encourage cool, bland fluids (water, diluted juice, popsicles) and soft foods if mouth lesions are present.
Implementation & Evaluation: Provide written instructions. Ask the mother to demonstrate back the key points, especially medication dosing and isolation criteria. Schedule a follow-up call in 24-48 hours to assess for complications like increased fever, lethargy, or signs of skin infection (increased redness, swelling, pus).
Patient Safety and Precautions:
Aspirin Contraindication: This is a critical safety point. Double-check any over-the-counter medications the family plans to use.
Recognizing Complications: Educate parents on "red flag" symptoms requiring immediate medical attention: difficulty breathing (pneumonia), severe headache/vomiting/confusion (encephalitis), or spreading redness/pus/warmth around lesions (cellulitis).
High-Risk Contacts: Identify if any household contacts are pregnant women, newborns, or immunocompromised individuals, as they are at risk for severe disease and may need post-exposure prophylaxis (varicella-zoster immune globulin - VZIG).
Nursing Procedure & Medication FlowPatient/Family Education Procedure:
1. Gather: Provide written materials on varicella care.
2. Explain: Use simple language. "The rash will be very itchy. If he scratches, the sores can get infected. So, we keep his nails super short like this."
3. Demonstrate: Show how to apply calamine lotion with a cotton ball.
4. Verify: Use teach-back method. "Mrs. Jones, can you tell me when Liam can go back to play with his friends?"
Medication Administration Cautions:
- Acetaminophen: Max dose 15 mg/kg every 4-6 hours. Warn not to combine with other products containing acetaminophen.
- Ibuprofen: Dose 10 mg/kg every 6-8 hours. Administer with food/milk.
- NEVER Aspirin: Reinforce this multiple times.
A Word from Your Senior Nurse
"In pediatrics, your patient is both the child and the family. A scared mom with an itchy, miserable kid needs clear, actionable advice. 'Keep the nails short' is tangible—she can do that right now and feel in control. Always connect your teaching to the 'why': 'We do this to prevent a worse infection that could need antibiotics or even a hospital stay.' This approach builds trust and ensures compliance. On the NCLEX, they're testing if you know the safest, most fundamental care. In real life, you're empowering a family to navigate a common but stressful childhood illness. That's the heart of nursing."