A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?
Flaring of the nares.
Resting respiratory rate of 35 breaths/minute.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
The Correct Answer is A
Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.
A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the most appropriate intervention for the PN to implement when approaching a client who is exhibiting compulsive behavior. By allowing time for the behavior, the PN acknowledges the client's need to perform the behavior and avoids creating further stress for the client. Redirecting the client to other activities can also help to refocus the client's behavior and prevent further compulsive behavior.
Encouraging the client to be calm and relax for a little while (A) may not be effective in managing the compulsive behavior.
Teaching the client thought-stopping techniques and ways to refocus behaviors (C) and assisting the client to identify stimuli that precipitate the activity (D) are interventions that may be used in the long term, but they may not be immediately effective in managing the client's behavior in the moment.
Correct Answer is B
Explanation
The PN should inform the client that athlete's foot is a fungal infection and that antibiotics are not effective against fungi. The client needs to use an antifungal medication to treat the infection. The other options are not accurate or appropriate responses.
Antibiotics take a week to be effective against the infection (A) is not accurate because antibiotics are not effective against fungal infections.
When the itching stops, continue to use the ointment for two weeks (C) is not appropriate because the client is using the wrong type of medication.
A thick layer of the medication is needed to stop the itching (D) is not accurate because the client is using the wrong type of medication.
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