A 6-year-old child is admitted to the pediatric unit with a diagnosis of measles. Which nursing intervention should be the priority?
1Administer acetaminophen for fever reduction
2Implement strict isolation precautions✓ 정답
3Encourage increased fluid intake
4Apply cool compresses to the rash
해설
Strict isolation is the priority for measles to prevent airborne spread. Aspirin is contraindicated in children due to Reye's syndrome risk; use acetaminophen instead.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a child with Measles (Rubeola). Measles is a highly contagious viral infection spread via airborne transmission. The priority in nursing care for any communicable disease is always infection control and prevention of transmission to protect other vulnerable patients, healthcare workers, and the community. This aligns with the nursing process principle of safety first.
Answer Rationale: Key Point! The correct answer is Implement strict isolation precautions. Measles virus can remain infectious in the air for up to two hours after an infected person leaves the area. Therefore, Airborne Precautions are mandatory. This includes placing the patient in a negative-pressure isolation room, ensuring all healthcare personnel wear an N95 respirator or equivalent, and restricting visitors. This intervention directly addresses the most significant risk: a widespread outbreak.
Distractor Analysis:
• Watch out for confusion!Administer acetaminophen for fever reduction: While fever management is important for comfort and preventing febrile seizures, it is a supportive measure, not the priority from a public health and safety standpoint. The NCLEX often prioritizes interventions that protect others or prevent harm over comfort measures.
• Encourage increased fluid intake: This is also a correct and important supportive intervention to prevent dehydration, especially with fever. However, it does not take precedence over containing a highly infectious agent.
• Apply cool compresses to the rash: This is generally not recommended for the measles rash. The rash is not typically pruritic (itchy) like chickenpox, and cool compresses are not a standard intervention. Comfort measures like maintaining a cool environment and using mild, non-medicated lotions might be used, but this is the least priority.
Related Concepts: Understanding the mode of transmission dictates the type of isolation. Measles requires Airborne Precautions. Compare this to chickenpox (Varicella) and disseminated herpes zoster, which also require Airborne and Contact Precautions. Diseases like influenza require Droplet Precautions.
Nursing Clinical Practice GuideClinical Scenario: You are a nurse on a pediatric unit. A 6-year-old named Leo is admitted with high fever, cough, coryza (runny nose), conjunctivitis, and the characteristic Koplik's spots (tiny white spots on the buccal mucosa). A maculopapular rash begins on his face and spreads downward. The physician diagnoses measles.
Nursing Intervention Strategy:
1Immediate Action (Priority)Immediately place Leo in a negative-pressure airborne infection isolation room (AIIR). Don appropriate PPE (N95 respirator, gown, gloves) before entering. Place clear signage on the door. Notify infection control.
2AssessmentMonitor vital signs, especially temperature and respiratory status. Assess for complications like otitis media, pneumonia, or encephalitis (lethargy, headache, vomiting, seizures).
3Supportive CareAdminister antipyretics like acetaminophen (avoid aspirin). Encourage clear fluids and a soft diet. Dim lights if photophobia is present. Provide quiet activities.
4Patient/Family EducationEducate the family on the importance of isolation, the course of the illness, and signs of complications. Emphasize that the child is contagious from 4 days before to 4 days after the rash appears.
Patient Safety and Precautions: Verify immunization status of staff and susceptible visitors. Aspirin is absolutely contraindicated due to the risk of Reye's syndrome. Monitor closely for signs of secondary bacterial infection.
Nursing Procedure & Medication FlowAirborne Precautions Procedure:
• Room: Negative pressure, private, door closed.
• PPE: N95 respirator (must be fit-tested) worn before entry.
• Transport: Limit strictly. If essential, patient wears a surgical mask.
• Duration: For measles, maintain precautions for 4 days after rash onset in healthy people; for immunocompromised, for duration of illness.Medication: Acetaminophen (Tylenol):
• Dose: 10-15 mg/kg/dose every 4-6 hours as needed for fever >38.5°C (101.3°F).
• Route: Oral or rectal.
• Caution: Do not exceed 5 doses in 24 hours. Check for liver disease.
A Word from Your Senior Nurse
"In pediatrics, seeing a child with a classic disease like measles is a powerful reminder of why vaccination is so crucial. In the hospital, your first thought must always be: 'Is this a risk to others?' For airborne diseases, the answer is a resounding yes. Your swift action to isolate protects every newborn, every chemo patient, and every elderly person on your unit. Never underestimate your role as the first line of defense in infection prevention. On the NCLEX, when you see 'priority' and a highly contagious disease, think 'transmission prevention' first!"
Measles — A highly contagious viral illness characterized by fever, cough, coryza, conjunctivitis, Koplik's spots, and a descending maculopapular rash. Spread via airborne transmission.
Airborne Precautions — Infection control measures for diseases transmitted via airborne droplet nuclei (small particles that remain suspended in air). Requires a negative-pressure room and N95 respirator. Examples: Measles, Tuberculosis, Varicella.
Koplik's Spots — Pathognomonic sign of measles; small, white, bluish-white spots with a red halo on the buccal mucosa opposite the molars, appearing 1-2 days before the rash.
Reye's Syndrome — A rare but serious condition causing swelling in the liver and brain, strongly associated with aspirin use in children with viral infections like influenza or chickenpox.
Droplet Precautions — Infection control measures for diseases transmitted via large respiratory droplets (e.g., from coughing, sneezing). Requires a private room or cohorting and a surgical mask. Examples: Influenza, Pertussis, Meningitis.