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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Egocentrism is a characteristic of cognitive development typically seen in the preoperational stage (2-7 years), where children believe everyone sees the world as they do. However, expressing sadness about being home alone does not specifically indicate egocentrism.

Choice B rationale

Magical thinking, also a characteristic of the preoperational stage, involves beliefs that thoughts can cause actions. Feeling sad about being home alone could be a manifestation of this, as the child might believe their sadness can change the situation.

Choice C rationale

Centration is the tendency to focus on one aspect of a situation and neglect others. The child’s statement does not provide evidence of centration.

Choice D rationale

Reversibility, the understanding that actions can be reversed, is a characteristic of the concrete operational stage (7-11 years)14. The child’s statement does not provide evidence of reversibility.

A. These therapies will decrease our child’s resistance to respiratory infections. B. These therapies will only be done when our child is showing signs of illness. C. These therapies will help to loosen our child’s secretions and allow for better expectoration. D. These therapies will allow for the removal of mucus from our child’s GI tract that blocks digestion.

Correct Answer is C

Explanation

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A child is admitted to the hospital.Which of the following findings is of greatest concern?

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Naxlex Comprehensive Predictor Exams

The nurse recognizes that a 4-year-old hospitalized child is exhibiting which characteristic of cognitive development, when the child tells the nurse it’s sad to be at home alone?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A child is admitted to the hospital.
Which of the following findings is of greatest concern?