A caregiver calls the pediatrician’s office and reports to the nurse that her 4-year-old, who was fine the previous day, complained of a sore throat early in the morning and now has a temperature of 102.6°F (39.2°C). The caregiver has tried to get the child to nap but the child gets panicky, sits back up, and leans forward with her mouth open and tongue out when the caregiver encourages her to lie down. The nurse suspects the child has which condition?

Epiglottitis

Mild asthma

Spasmodic laryngitis

Acute laryngotracheobronchitis

Answer and Explanation

The Correct Answer is A

A. Epiglottitis:

Epiglottitis is an inflammation of the epiglottis, which can result in rapid onset of symptoms such as severe sore throat, high fever, and difficulty breathing. The characteristic position described, with the child preferring to sit up, lean forward, and keep the mouth open, is known as the "tripod position." This is a protective mechanism to maintain a patent airway.

B. Mild asthma:

Asthma is a chronic respiratory condition characterized by recurrent episodes of wheezing, coughing, and shortness of breath. However, the scenario does not describe typical asthma symptoms, and the child's preference for sitting up and leaning forward is more indicative of an airway obstruction.

C. Spasmodic laryngitis:

Spasmodic laryngitis is characterized by sudden episodes of severe respiratory distress, a barking cough, and sometimes stridor. It often occurs at night and is usually not associated with high fever. The child's behavior in the scenario, particularly the preference for sitting up and leaning forward, is not a common feature of spasmodic laryngitis.

D. Acute laryngotracheobronchitis:

Acute laryngotracheobronchitis, or croup, typically presents with a barking cough, stridor, and respiratory distress. It does not usually cause the preference for sitting up and leaning forward as described in the scenario. Croup is more commonly associated with a distinctive cough sound.

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Free Nursing Study Resources

Correct Answer is ["-195"]

Explanation

The water intake is half of 900 mL, which is 450 mL. The soft drink intake is 12 oz, which is equivalent to 355 mL. Therefore, the total fluid intake is 450 + 355 = 805 mL.

The urine output is the sum of the two voids, which is 600 + 350 = 950 mL. The drainage output is 50 mL. Therefore, the total fluid output is 950 + 50 = 1000 mL.

The net I/O is the difference between the fluid intake and output, which is 805 - 1000 = -195 mL. This means that the patient had a negative fluid balance of 195 mL during the night.

A. Preventing spread of infection B. Maintaining skin integrity C. Improving nutrition D. Promoting comfort

Correct Answer is A

Explanation

A. Preventing spread of infection:

This is the highest priority goal because individuals with acquired immunodeficiency syndrome (AIDS) have a severely compromised immune system, making them more susceptible to infections. Preventing the spread of infection is crucial not only for the individual's well-being but also to reduce the risk of transmitting the virus to others.

B. Maintaining skin integrity:

Skin integrity is important, but it may not be the highest priority compared to preventing the spread of infection. Skin breakdown can occur in individuals with compromised immune systems, making them more susceptible to infections, but direct measures to prevent infection take precedence.

C. Improving nutrition:

Nutrition is vital for overall health, including immune function. However, in the context of AIDS, preventing the spread of infection is considered a higher priority. Nutritional support is important but may be addressed concurrently with other goals.

D. Promoting comfort:

Comfort is an important aspect of care, but it may not be the highest priority when compared to preventing the spread of infection. Comfort measures can be integrated into the overall care plan, but infection prevention takes precedence due to the immunocompromised state of the individual.

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Naxlex Comprehensive Predictor Exams

The client voided twice on your shift (600 mL, 350 mL) and drank half of his 900mL water pitcher plus a 12 oz soft drink during the night. There was 50 mL drainage from the hemovac during the night. Calculate the patient’s total I/O starting at 2300 and ending at 0700.

Correct Answer is ["-195"]

Explanation

The nurse is caring for a 16-year-old child with a diagnosis of acquired immunodeficiency syndrome (AIDS). What treatment goal has the highest priority for this child?

Correct Answer is A

Explanation

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