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?

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.

Choice A reason: Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.

Choice B reason: Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.

Choice C reason: Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.

Choice D reason: Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.