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

Answer and Explanation

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.

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Correct Answer is C

Explanation

a) Focusing exclusively on the reported illness: Given the regular visits and the gap since the last well-child visit, it's essential to consider a broader perspective beyond the reported illness.

b) Asking the mother to leave the room after obtaining their history: This situation doesn't suggest the need to exclude the mother from the discussion.

c) Obtaining a comprehensive history, including socio-economic data: This approach considers the child's health within a broader context, taking into account any changes or potential factors influencing the child's health.

d) Reviewing health promotion and maintenance activities: While important, this situation requires a broader assessment due to the gap between visits and a sick visit.

A. Refer children with sore throats for throat cultures B. Conduct routine blood pressure screenings C. Recommend salicylates instead of ibuprofen for minor discomforts D. Encourage routine cholesterol screenings

Correct Answer is A

Explanation

a) Refer children with sore throats for throat cultures: Early detection and treatment of Group A streptococcal infections are crucial in preventing rheumatic fever. Throat cultures help identify the presence of streptococcal bacteria.

b) Conduct routine blood pressure screenings: While important for other health concerns, blood pressure screenings are not directly related to preventing rheumatic fever.

c) Recommend salicylates instead of ibuprofen for minor discomforts: Salicylates are not the primary intervention for preventing rheumatic fever; prompt antibiotic treatment for streptococcal infections is key.

d) Encourage routine cholesterol screenings: Cholesterol screenings are unrelated to the prevention of rheumatic fever.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A mother brings her 2-year-old child to the pediatric office for a sick visit. The child is seen regularly at the office and was last seen at her well-child visit two months ago. Based on this information, which is the most appropriate action by the nurse?

Correct Answer is C

Explanation

Which of the following actions by the school nurse is important in the prevention of rheumatic fever (RF)?

Correct Answer is A

Explanation

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