A 2-year-old child has had a common cold for 4 days. The caregiver calls the nurse in the emergency department at 2 a.m. on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; the child seems blue around the mouth. The nurse would appropriately recommend what action to the caregiver?
“Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there is no relief in an hour.”
“Bring the child to the emergency room immediately.”
“Bundle the child up and take the child out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief.”
“Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam-filled room for 15 minutes. If there is no relief, bring the child to the emergency room.”
The Correct Answer is B
Choice A reason: A cool mist humidifier may help croup but is inadequate for a child with a barking cough, fever, and cyanosis (blue around the mouth), indicating severe respiratory distress. Immediate ER evaluation is critical, making this insufficient and incorrect for the urgent symptoms described in the scenario.
Choice B reason: A barking cough, fever, and cyanosis suggest severe croup or airway obstruction, requiring urgent medical evaluation. Bringing the child to the ER immediately ensures timely intervention for potential respiratory compromise, aligning with pediatric emergency protocols, making it the correct recommendation for the caregiver.
Choice C reason: Cold air exposure may temporarily relieve croup but is unsafe for a cyanotic child with fever, indicating severe distress. Immediate ER care is needed to address potential airway issues, making this risky and incorrect for managing the child’s critical symptoms in this urgent situation.
Choice D reason: Steam may help mild croup but delays care for a child with cyanosis, signaling severe respiratory compromise. Immediate ER evaluation is essential to prevent deterioration, making this inadequate and incorrect compared to the urgent need for professional assessment in the emergency department.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Family health history identifies genetic and environmental risk factors, enabling preventive measures to reduce the child’s likelihood of developing similar conditions. This aligns with pediatric health assessment goals, making it the correct explanation for gathering family health history data during the clinical encounter.
Choice B reason: Family history does not force parental behavior changes but informs risk assessment. Suggesting coercion is inaccurate, as the goal is prevention through awareness, making this incorrect compared to identifying risk factors as the primary reason for collecting health history from the parents.
Choice C reason: Needing to know “everything” is overly broad and impractical. Family health history specifically targets relevant risk factors for the child’s health, not all family details, making this vague and incorrect for the focused purpose of gathering targeted medical history during the assessment.
Choice D reason: The number of affected family members informs risk but does not definitively predict the child’s health outcomes. Identifying risk factors for prevention is the broader goal, making this too narrow and incorrect for the primary reason for collecting family health history in pediatric care.
Correct Answer is C
Explanation
Choice A reason: Lack of eye contact and developmental delay don’t directly indicate physical abuse, which typically shows fear or physical signs. Autistic behaviors like poor eye contact are more likely, making this incorrect, as the toddler’s behaviors align better with autism in the well-child assessment.
Choice B reason: Cocaine abuse by the caregiver might affect development but isn’t linked to specific behaviors like poor eye contact. Autistic traits better explain the toddler’s symptoms, making this speculative and incorrect compared to the nurse’s assessment of developmental concerns in the child.
Choice C reason: Poor eye contact and slower development at 23 months suggest autistic behaviors, common in autism spectrum disorder. This aligns with pediatric developmental screening, making it the correct additional assessment for the nurse to consider based on the toddler’s observed behaviors during the check.
Choice D reason: ADHD typically presents later with hyperactivity and inattention, not poor eye contact or developmental delay at 23 months. Autistic behaviors are more fitting, making this incorrect, as the toddler’s symptoms align better with autism than ADHD in the well-child evaluation.
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