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 D
Explanation
Choice A rationale
Post-traumatic stress disorder (PTSD) is a mental health condition that’s triggered by a terrifying event. Symptoms may include flashbacks, nightmares, and severe anxiety. However, a 2-year-old child may not have the cognitive ability to develop PTSD as it requires a certain level of cognitive and psychological development.
Choice B rationale
While separation anxiety is a normal stage of development for infants and toddlers, a 2-year- old child in a burn unit is more likely to be afraid of the pain associated with wound dressing changes rather than being separated from his/her parents.
Choice C rationale
Fear of permanent scarring could be a concern for older children and adults who are more aware of their body image. A 2-year-old child may not have the cognitive ability to understand the concept of permanent scarring.
Choice D rationale
The child is likely worried about the pain associated with the procedure. Pain experienced by patients is likely to increase during procedures such as dressing changes. This is a common and immediate fear for children undergoing medical procedures, especially those associated with pain.
Correct Answer is A
Explanation
Choice A rationale
Supervising the child in outdoor, fenced play areas is a key safety measure for toddlers. At this age, children are exploring their environment and may not be aware of potential dangers.
Fenced play areas provide a safe space for the child to play while still being under the watchful eye of the parents. This demonstrates an understanding of the child’s safety needs.
Choice B rationale
Allowing a toddler to cross the street with a 6-year-old sibling is not a safe practice. Children at this age do not have the cognitive ability to understand the dangers of traffic and cannot make safe decisions about when to cross the street. Therefore, this action does not demonstrate an understanding of the child’s safety needs.
Choice C rationale
Using an automobile booster seat with a lap belt is not appropriate for an 18-month-old toddler. According to safety guidelines, children under the age of 2 should be in a rear-facing car seat, and children between the ages of 2 and 4 should be in a forward-facing car seat with a harness. Booster seats are typically used for older children who have outgrown their forward- facing car seats. Therefore, this action does not demonstrate an understanding of the child’s safety needs.
Choice D rationale
Teaching a toddler about swimming and water safety is important, but it is not enough to ensure the child’s safety. Toddlers should always be supervised around water, even if they have had swimming lessons. Drowning is a leading cause of death in toddlers, and it can happen quickly and silently. Therefore, while teaching water safety is a good step, it needs to be combined with other safety measures.
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