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 C
Explanation
Choice A reason: Eating with family may encourage variety but does not address the normalcy of food jags in 6-year-olds. Reassuring about their transient nature reduces caregiver stress, making this less direct and incorrect compared to normalizing the child’s selective eating behavior for the concerned caregiver.
Choice B reason: Insisting on variety at every meal may escalate mealtime stress, as food jags are normal and temporary in 6-year-olds. Acknowledging their common occurrence is more supportive, making this pressuring and incorrect for addressing the caregiver’s nutritional concern about the child’s eating habits.
Choice C reason: Food jags, where a child fixates on one food, are common at age 6 and typically resolve naturally. Reassuring the caregiver reduces anxiety and aligns with pediatric nutrition guidance, making this the prioritized response to address concerns about the child’s nutrition and eating patterns.
Choice D reason: Discouraging food preferences risks mealtime conflicts, as food jags are developmentally normal. Normalizing their temporary nature supports the caregiver without forcing the child, making this unhelpful and incorrect compared to reassuring about the common, transient behavior in 6-year-olds.
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Normal heart rate and respirations indicate reduced physiological stress from pain, supporting effective medication in a terminally ill child. This aligns with pediatric pain assessment criteria, making it a correct assessment to document as evidence of successful pain relief post-medication administration.
Choice B reason: Withdrawing from the environment suggests ongoing distress or pain, not relief. Normal vitals and low pain scores indicate effectiveness, making this incorrect, as it reflects a negative outcome rather than supporting successful pain management in the terminally ill child’s evaluation.
Choice C reason: A flexed position may indicate persistent pain or discomfort, not relief. Sleeping or low pain scores better demonstrate effectiveness, making this incorrect, as it does not support the medication’s success in alleviating pain in the terminally ill client during the assessment.
Choice D reason: Verbalizing a 1 on the pain scale directly indicates minimal pain, confirming the medication’s effectiveness in a terminally ill child. This aligns with pediatric pain management standards, making it a correct assessment to document as evidence of successful pain relief post-administration.
Choice E reason: Quietly sleeping on the parent’s lap suggests comfort and pain relief, a positive sign in a terminally ill child. This aligns with behavioral pain assessment in pediatrics, making it a correct observation to document as evidence of effective medication for pain management.
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