A mother calls her pediatrician's office concerned about her 7-month-old son. She gave him peanuts for the second time for lunch and he has vomited three times is coughing and looks flushed. What is the priority of the nurse?
Give Benadryl PO and monitor for the next 2 hours
Recommend symptomatic treatment for the cough
Tell the mother to call 911
Administer CPR to the child
The Correct Answer is C
The symptoms described, including vomiting, coughing, and looking flushed, are concerning for a potentially severe allergic reaction, which can be life-threatening. This could be indicative of anaphylaxis, a severe allergic reaction that requires immediate medical attention.
Administering CPR (Option D) is not appropriate at this point unless the child becomes unresponsive and stops breathing, which would be a very late sign of anaphylaxis. In such a situation, CPR would be necessary, but the primary focus should be on calling 911 and obtaining immediate medical assistance.
Option A, giving Benadryl, can be part of the treatment for an allergic reaction, but it should not be the first or only action taken in a severe allergic reaction. Immediate medical evaluation and potential administration of epinephrine are more critical.
Option B, recommending symptomatic treatment for the cough, is not appropriate in this situation. The priority is recognizing the potential severity of the allergic reaction and seeking immediate emergency care.
Therefore, the nurse should advise the mother to call 911 to ensure that the child receives prompt medical attention and assessment for anaphylaxis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Kawasaki disease is a rare but serious condition that primarily affects children, particularly those under the age of 5. It is characterized by inflammation of the blood vessels throughout the body, including the coronary arteries. If left untreated, Kawasaki disease can lead to the development of aneurysms in the coronary arteries. These aneurysms can put the child at risk for complications such as thrombosis (clot formation) or rupture of the affected arteries, which can be life-threatening.
The other options (A, C, and D) are not typically associated with Kawasaki disease:
A. Sepsis: Kawasaki disease is not an infectious disease, and it does not directly lead to sepsis. It is an inflammatory condition believed to have an autoimmune component.
C. Meningitis: Kawasaki disease primarily affects blood vessels and does not lead to the development of meningitis.
D. Mitral valve disease: While Kawasaki disease can affect the cardiovascular system, it is not a direct cause of mitral valve disease. The development of mitral valve disease would be a separate cardiac issue unrelated to Kawasaki disease.
Correct Answer is E
Explanation
Infective endocarditis is an infection of the inner lining of the heart chambers and valves. One of the hallmark signs of infective endocarditis is fever, often accompanied by other symptoms such as fatigue, chills, and joint pain. A persistent fever in a child, especially when associated with other signs or symptoms like new heart murmurs or petechiae (small red or purple spots on the skin), can be concerning for infective endocarditis.
The other symptoms and findings listed (proteinuria, ESR, weight gain, hemoglobin levels) are not specific to infective endocarditis and may have other potential causes or interpretations. It is important to consider a comprehensive clinical evaluation and laboratory tests when assessing a child with suspected infective endocarditis.
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