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 A
Explanation
Choice A rationale
Adolescents are capable of abstract thinking and can participate in planning. This cognitive development allows them to understand the long-term consequences of their food choices and participate in planning their meals.
Choice B rationale
Adolescents are capable of understanding quantity of mass even if you change the shape. This is a cognitive ability typically developed during the concrete operational stage of cognitive development, which occurs between the ages of 7 and 1189.
Choice C rationale
Adolescents are capable of thinking critically about food choices. With the right guidance and information, they can make informed decisions about their diet.
Choice D rationale
Adolescents are capable of understanding in abstract terms, not just concrete terms. They can understand complex concepts and hypothetical scenarios, which can help them make informed decisions about their food choices.
Correct Answer is D
Explanation
Choice A rationale
While providing oxygen can be important in the care of a newborn with esophageal atresia, it is not the first priority. These babies often have difficulty breathing, but this is usually due to the abnormal connection between the esophagus and the trachea (tracheoesophageal fistula), which allows stomach acid to enter the lungs. Oxygen therapy alone does not address this underlying problem.
Choice B rationale
Placing the infant in an isolette or radiant warmer is not the first priority. While maintaining the baby’s body temperature is important, it does not address the immediate risks associated with esophageal atresia.
Choice C rationale
Obtaining a stat chest X-ray can be part of the diagnostic process for esophageal atresia, but it is not the first priority. The diagnosis is usually suspected based on symptoms such as frothy bubbles in the mouth and nose, coughing or choking when feeding, and difficulty breathing.
Choice D rationale
Elevating the head of the bed 30 to 35 degrees is the first priority. This position helps to prevent aspiration of gastric contents into the lungs, which can occur due to the abnormal connection between the esophagus and the trachea (tracheoesophageal fistula) that is often present in babies with esophageal atresia.
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