A 4-year-old girl is brought to the emergency department. She has a ‘frog-like’ croaking sound on inspiration, is agitated, and drooling. She insists on sitting upright. The nurse should do which of the following?
Make her lie down and rest quietly
Examine her oral pharynx and report to the physician
Auscultate her lungs and prepare for placement in a warm mist tent
Defer an oral assessment and be prepared to assist with a tracheostomy or intubation
The Correct Answer is D
a) Make her lie down and rest quietly: Inappropriate as the symptoms suggest potential airway obstruction.
b) Examine her oral pharynx and report to the physician: Important action, but immediate airway management is the priority.
c) Auscultate her lungs and prepare for placement in a warm mist tent: Less critical than ensuring an open airway.
d) Defer an oral assessment and be prepared to assist with a tracheostomy or intubation: The child's symptoms (stridor, agitation, drooling) indicate potential upper airway obstruction, and immediate readiness for airway intervention is essential.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a) Projectile vomiting: A hallmark symptom of pyloric stenosis due to the narrowing of the pyloric sphincter, leading to forceful and projectile vomiting.
b) Watery diarrhea: Not typically associated with pyloric stenosis.
c) Increased urine output: Unrelated to pyloric stenosis, urinary output might vary based on other factors.
d) Bloody stools: Typically not a primary symptom of pyloric stenosis, which primarily affects the passage of food from the stomach.
Correct Answer is A
Explanation
a) Promoting healthy mental-health outcomes: The primary focus should be on the client's emotional well-being and helping them cope with the feelings of loneliness and adjustment to a new environment.
b) Helping the school-age client register the value of soccer: While beneficial, it's secondary to addressing the client's emotional state.
c) Stressing the importance of remaining in close parent-child relationships: Important, but not the immediate priority in this situation.
d) Acknowledging the fact that it might take several months to make new friends at this school: Valid, but addressing the immediate emotional distress is more crucial.
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