A child is admitted to the hospital.
Which of the following findings is of greatest concern?
The child is restless, has bilateral wheezes, and poor feeding.
The patient is sitting up and has coarse breath sounds, coughing, and restlessness.
The child has not been eating well and has had an increased respiratory effort.
The toddler is in the tripod position, has diminished breath sounds, and grunting.
The Correct Answer is D
Choice A rationale
Restlessness, bilateral wheezes, and poor feeding are concerning symptoms in a child. Restlessness can indicate discomfort or distress. Bilateral wheezes can suggest an airway obstruction or inflammation, often seen in conditions like asthma. Poor feeding can be a sign of general illness or specific conditions like gastrointestinal disorders. However, these symptoms, while concerning, are not as immediately threatening as the symptoms described in choice D12.
Choice B rationale
Sitting up, coarse breath sounds, coughing, and restlessness are also concerning symptoms. Coarse breath sounds and coughing can indicate a respiratory infection or other lung condition. Restlessness can again indicate discomfort or distress. However, these symptoms are not as immediately threatening as the symptoms described in choice D12.
Choice C rationale
Not eating well and increased respiratory effort are signs of potential illness. Not eating well can lead to malnutrition and weakened immunity, making the child more susceptible to infections and slowing recovery. Increased respiratory effort can be a sign of respiratory distress, which could be due to conditions like pneumonia or asthma. However, these symptoms are not as immediately threatening as the symptoms described in choice D12.
Choice D rationale
A toddler in the tripod position (sitting up and leaning forward, using the arms to support the upper body), with diminished breath sounds and grunting, is showing signs of severe respiratory distress. The tripod position is often used instinctively to maximize airway patency and ease breathing. Diminished breath sounds can indicate significant airway obstruction or lung disease. Grunting is a sign of increased work of breathing and is often seen in conditions like pneumonia or severe asthma. These symptoms together suggest that the child may be in respiratory failure, which is a life-threatening emergency requiring immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
An eight-year-old child who weighs 60 pounds, rides a bike without training wheels, and is an active swimmer is showing appropriate developmental milestones for their age. Riding a bike and swimming are complex activities that require good motor coordination and balance. These activities also indicate that the child is physically active, which is beneficial for overall health.
Choice B rationale
A three-year-old child who weighs 28 pounds, requires help with feeding, dislikes most foods, and refuses to drink milk may be showing signs of a feeding disorder or picky eating, which can lead to nutritional deficiencies and impact growth and development. This child requires further evaluation to determine the cause of these feeding difficulties and to develop a plan to address them.
Choice C rationale
A six-month-old who weighs 16 pounds, continues to breastfeed, has started solid foods, and is beginning to crawl is showing appropriate developmental milestones for their age. The World Health Organization recommends exclusive breastfeeding for the first six months of life, followed by the introduction of appropriate complementary foods. Crawling is also a typical developmental milestone that usually appears between 6 and 10 months of age.
Choice D rationale
A four-year-old child who weighs 40 pounds, eats from the same plate every meal, and is occasionally a picky eater is within normal behavior for their age. It’s common for
preschoolers to have food preferences and to want routines, such as using the same plate. Picky eating is also a common behavior at this age and usually isn’t a cause for concern unless it leads to nutritional deficiencies or other health problems.
Correct Answer is C
Explanation
Choice A rationale
These therapies will decrease our child’s resistance to respiratory infections. This statement is incorrect. The therapies mentioned - chest physiotherapy (CPT), use of a flutter valve, and a cough assist machine - do not directly decrease a child’s resistance to respiratory infections.
Instead, they help manage the symptoms of cystic fibrosis by helping to clear mucus from the lungs, which can improve lung function and reduce the risk of lung infections.
Choice B rationale
These therapies will only be done when our child is showing signs of illness. This statement is incorrect. These therapies are part of the daily management of cystic fibrosis and are typically done regularly, not just when the child is showing signs of illness.
Choice C rationale
These therapies will help to loosen our child’s secretions and allow for better expectoration. This statement is correct. The goal of these therapies is to help clear thick, sticky mucus from the lungs, which can improve breathing and reduce the risk of lung infections.
Choice D rationale
These therapies will allow for the removal of mucus from our child’s GI tract that blocks digestion. This statement is incorrect. While cystic fibrosis can affect the digestive system by causing thick mucus to block the tubes that carry digestive enzymes from your pancreas to your small intestine, the therapies mentioned are primarily used to help clear mucus from the lungs.
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