A 2-year-old child admitted to a burn unit with second and third-degree burns is scheduled for another wound dressing change.
The child is anticipating the painful procedure and is anxious and tachycardic as the time approaches. The nurse recognizes that which of the following is likely?

The child is suffering post-traumatic stress.

The child is fearful of being separated from his/her parents.

The child is fearful of permanent scarring.

The child is worried about the pain associated with the procedure.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event. Symptoms may include flashbacks, nightmares, and severe anxiety. However, a 2-year-old child may not have the cognitive ability to develop PTSD as it requires a certain level of cognitive and psychological development.

Choice B rationale

While separation anxiety is a normal stage of development for infants and toddlers, a 2-year- old child in a burn unit is more likely to be afraid of the pain associated with wound dressing changes rather than being separated from his/her parents.

Choice C rationale

Fear of permanent scarring could be a concern for older children and adults who are more aware of their body image. A 2-year-old child may not have the cognitive ability to understand the concept of permanent scarring.

Choice D rationale

The child is likely worried about the pain associated with the procedure. Pain experienced by patients is likely to increase during procedures such as dressing changes. This is a common and immediate fear for children undergoing medical procedures, especially those associated with pain.

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Correct Answer is A

Explanation

Choice A rationale

Seizures, confusion, and weakness are symptoms that a nurse should anticipate when assessing a child suffering from hypotonic hyponatremia with a sodium level below 114

mEq/L2. Severe hyponatremia can lead to cerebral edema, resulting in neurologic symptoms such as seizures and confusion.

Choice B rationale

Mild tingling and numbness in fingers are not typically associated with hyponatremia. These symptoms are more commonly associated with conditions affecting the nervous system or with electrolyte imbalances such as hypocalcemia.

Choice C rationale

Frequent urination and fluid retention are not typical symptoms of hyponatremia. They are more commonly associated with conditions such as kidney disease or heart failure.

Choice D rationale

A temperature of 96°F orally and drowsiness are not specific symptoms of hyponatremia. While drowsiness can occur with severe hyponatremia due to cerebral edema, a low body temperature is not typically associated with this condition.

A. A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93%. B. A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93%. C. A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93%. D. A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93%.

Correct Answer is A

Explanation

Choice A rationale

A 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93% is showing signs of severe respiratory distress. The weak cry and pale complexion suggest poor oxygenation and possible hypoxia. Decreased breath sounds and retractions indicate the child is struggling to breathe. An oxygen saturation of 93% is below the normal range for infants, further indicating respiratory distress. This child should be prioritized for treatment.

Choice B rationale

A 5-year-old speaking in full sentences, pink complexion, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress, but not as severe as Choice A12. The ability to speak in full sentences and having a pink complexion suggest that the child is getting

enough oxygen. However, bilateral wheezing indicates some airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for children this age.

Choice C rationale

A 16-year-old speaking in short phrases, wheezing, sitting upright, and an oxygen saturation of 93% is also showing signs of respiratory distress. Speaking in short phrases and sitting upright are signs that the teenager is working harder to breathe. Wheezing indicates airway obstruction. An oxygen saturation of 93% is on the lower end of the normal range for teenagers.

Choice D rationale

A 9-year-old who is quiet, pale, sitting on his father’s lap, bilateral wheezing, and an oxygen saturation of 93% is showing signs of respiratory distress. Being quiet and pale can indicate poor oxygenation. Bilateral wheezing suggests airway obstruction. An oxygen saturation of 93% is below the normal range for children this age. However, this child’s symptoms are not as severe as those of the 12-month-old in Choice A.

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A 2-year-old child admitted to a burn unit with second and third-degree burns is scheduled for another wound dressing change.The child is anticipating the painful procedure and is anxious and tachycardic as the time approaches. The nurse recognizes that which of the following is likely?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child who is suffering from hypotonic hyponatremia with a sodium level below 114 mEq/L. Which of the following symptoms will the nurse anticipate when assessing the child?

Correct Answer is A

Explanation

In the Emergency Department, four children are awaiting treatment for respiratory illnesses.Given that only one treatment room is available, which child should be prioritized based on the assessment findings?

Correct Answer is A

Explanation

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A 2-year-old child admitted to a burn unit with second and third-degree burns is scheduled for another wound dressing change.
The child is anticipating the painful procedure and is anxious and tachycardic as the time approaches. The nurse recognizes that which of the following is likely?