A 1-year-old child with respiratory syncytial virus (RSV) is admitted to the pediatric unit. The nurse observes that the child presents with a fever, rhinorrhea, frequent coughing, and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress?

Flaring of the nares.

Diaphragmatic respirations.

A resting respiratory rate of 35 breaths/min.

Bilateral bronchial breath sounds.

Answer and Explanation

The Correct Answer is A

Choice A reason: Flaring of the nares is a sign of acute respiratory distress in children. It indicates that the child is using the accessory muscles of the nose to breathe, which is a sign of increased work of breathing. Flaring of the nares may be accompanied by other signs of respiratory distress, such as retractions, grunting, or cyanosis. The nurse should report this finding to the health care provider and monitor the child's oxygen saturation, respiratory rate, and level of consciousness.

Choice B reason: Diaphragmatic respirations are not a specific sign of acute respiratory distress in children. They are a normal pattern of breathing in infants and young children, who use their diaphragm more than their chest muscles to breathe. Diaphragmatic respirations may become more pronounced when the child is crying, feeding, or sleeping, but they are not indicative of respiratory distress.

Choice C reason: A resting respiratory rate of 35 breaths/min is not a sign of acute respiratory distress in children. It is within the normal range for a 1-year-old child, who typically has a respiratory rate of 20 to 40 breaths/min. A resting respiratory rate of more than 60 breaths/min may be a sign of respiratory distress in children, especially if it is associated with other symptoms, such as wheezing, coughing, or nasal flaring.

Choice D reason: Bilateral bronchial breath sounds are not a sign of acute respiratory distress in children. They are normal breath sounds that are heard over the trachea and the large bronchi. They are loud and high-pitched, and have a longer expiratory phase than inspiratory phase. Bilateral bronchial breath sounds do not indicate any lung pathology or obstruction.

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Correct Answer is A

Explanation

Choice A reason: Instilling benzocaine otic drops regularly is not a recommended practice for preventing or treating otitis media. Benzocaine is a topical anesthetic that can temporarily relieve ear pain, but it does not address the underlying cause of the infection. Moreover, benzocaine can cause allergic reactions, skin irritation, or methemoglobinemia, a condition that reduces the oxygen-carrying capacity of the blood. The nurse should instruct the caregiver to avoid using benzocaine otic drops unless prescribed by a health care provider.

Choice B reason: Avoiding any smoking inside the house is a good practice for preventing otitis media. Smoking can irritate the respiratory tract and impair the function of the cilia, the hair-like structures that help clear mucus and bacteria from the middle ear. Smoking can also increase the risk of respiratory infections, allergies, and asthma, which are associated with otitis media. The nurse should praise the caregiver for avoiding smoking and encourage them to maintain a smoke-free environment for the infant.

Choice C reason: Giving the infant the full course of antibiotics is a necessary practice for treating otitis media. Antibiotics can help eliminate the bacteria that cause the infection and reduce the inflammation and pain in the middle ear. However, antibiotics should be used only when prescribed by a health care provider, and the caregiver should follow the instructions carefully. The nurse should remind the caregiver to give the infant the exact dose of antibiotics at the right time and for the entire duration of the treatment, even if the symptoms improve.

Choice D reason: Scheduling a visit for pneumococcal vaccine is a preventive measure for otitis media. Pneumococcal vaccine can protect the infant from the most common strains of Streptococcus pneumoniae, a bacterium that causes otitis media and other serious infections. The vaccine is recommended for all children under 2 years of age, and it is given in four doses at 2, 4, 6, and 12 to 15 months of age. The nurse should verify the infant's immunization status and advise the caregiver to follow the recommended schedule for the pneumococcal vaccine.

A. Obtain a swab of secretions from the penis and urethra. B. Collect a sterile urine sample for culture and sensitivity. C. Provide the adolescent with a urinal for urinary hesitancy. D. Report the findings immediately to the healthcare provider.

Correct Answer is D

Explanation

Choice A reason: Obtaining a swab of secretions from the penis and urethra is not the appropriate action to take in this situation. This may be done to test for sexually transmitted infections (STIs), such as chlamydia or gonorrhea, that can cause epididymitis, an inflammation of the tube that carries sperm from the testicle. However, epididymitis usually causes gradual pain and swelling, not sudden and severe, and is unlikely to be triggered by a physical activity. Moreover, obtaining a swab may be painful and unnecessary for the adolescent.

Choice B reason: Collecting a sterile urine sample for culture and sensitivity is not the appropriate action to take in this situation. This may be done to test for urinary tract infections (UTIs) or kidney stones that can cause testicular pain. However, UTIs and kidney stones usually cause other symptoms, such as burning or difficulty urinating, blood in the urine, or lower back pain. They are also unlikely to be triggered by a physical activity. Moreover, collecting a urine sample may be difficult and uncomfortable for the adolescent.

Choice C reason: Providing the adolescent with a urinal for urinary hesitancy is not the appropriate action to take in this situation. Urinary hesitancy is the difficulty or delay in starting or maintaining a urine stream. It can be caused by various factors, such as anxiety, medication, prostate problems, or nerve damage. It is not a common symptom of testicular pain and is not related to the cause of the pain. Moreover, providing a urinal may be embarrassing and unnecessary for the adolescent. ⁷

Choice D reason: Reporting the findings immediately to the healthcare provider is the appropriate action to take in this situation. Sudden and severe testicular pain and swelling can be a sign of testicular torsion, a medical emergency that occurs when the testicle twists and cuts off its blood supply. Testicular torsion can be caused by trauma, strenuous exercise, or cold temperature. It can lead to permanent damage or loss of the testicle if not treated promptly. The adolescent needs urgent evaluation and possible surgery to untwist the testicle and restore blood flow.

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A 1-year-old child with respiratory syncytial virus (RSV) is admitted to the pediatric unit. The nurse observes that the child presents with a fever, rhinorrhea, frequent coughing, and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress?

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Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?