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 A

Explanation

a) Red, currant, jelly-like stools: This is a classic indication of intussusception due to the presence of blood and mucus in the stool, a result of intestinal obstruction and ischemia.

b) Absent bowel sounds: Can occur but are not specific to intussusception.

c) Hematemesis: Vomiting blood is not a characteristic sign of intussusception.

d) Bilious emesis: While indicative of gastrointestinal issues, it's not the cardinal sign of intussusception.

A. Constipation B. Meconium ileus C. Rectal prolapse D. Steatorrhea stools

Correct Answer is B

Explanation

a) Constipation: Not typically a primary symptom of cystic fibrosis.

b) Meconium ileus: Meconium ileus is a bowel obstruction that occurs shortly after birth due to abnormally thick meconium. It is a classic early sign of cystic fibrosis in newborns. Other symptoms such as failure to thrive, persistent cough, salty-tasting skin, and recurrent respiratory infections may also manifest later.

c) Rectal prolapse: Can be related to cystic fibrosis but is not as specific as other symptoms.

d) Steatorrhea stools: Frequent fatty stools are symptoms of the disease but not specific to cystic fibrosis.

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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

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What is the cardinal sign a nurse would expect to observe with intussusception?

Correct Answer is A

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Correct Answer is B

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