A 6-year-old child is brought to the pediatric clinic with a 2-day history of fever and the appearance of small, fluid-filled vesicles on the trunk and face. The parent reports that the child has been scratching the lesions frequently. What is the most important assessment the nurse should perform first?
1Measure the child's temperature and assess for signs of dehydration
2Examine the lesions for signs of bacterial superinfection
3Assess the child's respiratory status and auscultate lung sounds✓ 정답
4Evaluate the child's pain level using an age-appropriate pain scale
해설
The priority assessment is respiratory status due to the risk of varicella pneumonia, a life-threatening complication. Other options address fever, superinfection, or pain, which are secondary concerns.
Clinical Judgment
This question asks about the prioritization of assessment for a child with Varicella. The key point is the "Most important First assessment". Although fever and vesicular rash are present, the nurse must always prioritize the ABCs (Airway, Breathing, Circulation). The most serious complication of varicella is varicella pneumonia, which occurs especially in adults and immunocompromised individuals but can also be life-threatening in children. Therefore, assessing the respiratory status first to check for signs of pneumonia such as cough, dyspnea, and abnormal auscultation findings is most important. All other options are necessary, but the possibility of a direct life threat must be ruled out first.
Memory Tip: When assessing a child with varicella, remember the ABCs. Airway & Breathing (respiratory status) are always more Critical than rash or pain.
KR vs US: In Korea, children with varicella are often treated at home with a focus on rash management and fever reduction, but the NGN/US approach emphasizes systematic screening for potential life-threatening complications, especially when immune status is unclear or respiratory symptoms are present.
임상 시나리오
Clinical Practice Guide
When evaluating a child with chickenpox, think of respiratory, neurological, and skin complications as a checklist.
1. Respiratory: cough, difficulty breathing, crackles/wheezing on auscultation, oxygen saturation.
2. Neurological: headache, vomiting, neck stiffness, altered consciousness (signs of encephalitis).
3. Skin: secondary bacterial infection of lesions (redness, tenderness, purulent discharge), hemorrhagic lesions.
Caution: In SATA (Select All That Apply) questions that ask for the "most important first action," you must select only one. You need to think, "All are important assessments, but prioritize the one that is directly life-threatening first." Even if a rash is present, ABCs come first.
핵심 개념
Varicella — Chickenpox. An acute infectious disease caused by the Varicella-Zoster Virus (VZV) of the herpesvirus family. Characteristically, skin lesions at different stages (macules, papules, vesicles, crusts) are present simultaneously.
Varicella Pneumonia — Varicella pneumonia. A serious complication that occurs when the varicella virus invades the lungs. It is more common in adults, pregnant women, and immunocompromised individuals, and can cause difficulty breathing, cough, and chest pain, and may be fatal.
Superinfection — Secondary infection or superinfection. A new infectious agent (mainly bacteria, e.g., Staphylococcus, Streptococcus) is added on top of an existing infection (here, viral chickenpox lesions). Redness, swelling, and purulent discharge appear.
Vesicle — Blisters. Small blisters less than 1 cm in diameter filled with serous fluid within the epidermis. Characteristic lesion of chickenpox.
Auscultation — Auscultation. An examination method that uses a stethoscope to listen to sounds produced within the body (e.g., lung sounds, heart sounds, bowel sounds). Essential for assessing respiratory complications.