A nurse is assessing a 2-year-old child with croup.
The child's mother states that the child has had a barking cough for 2 days, which is worse at night.
The child also has a fever and is hoarse.
Which of the following statements by the nurse is most appropriate?
"This sounds like croup.
"Croup is a serious condition.
"There's nothing we can do for croup.
"Croup is caused by a bacterial infection.
m going to give your child some antibiotics.”..
The Correct Answer is A
The nurse should assess the child's vital signs and listen to his lungs.
Choice A rationale:
Assessing vital signs, including heart rate, respiratory rate, oxygen saturation, and temperature, is essential in evaluating the child's overall condition and the severity of respiratory distress.
Listening to the child's lungs can help identify abnormal breath sounds, such as stridor or wheezing, which are common in croup.
This information guides further interventions and helps determine the appropriate level of care.
Choice B rationale:
While croup can cause respiratory distress, not every case requires an emergency room visit.
The severity of symptoms, including the child's ability to breathe and oxygenate, should guide the decision to seek emergency care.
In this scenario, assessing vital signs and lung sounds is the initial appropriate action.
Choice C rationale:
Croup is a treatable condition, and there are specific interventions, such as providing humidified air and corticosteroids, that can alleviate symptoms and prevent complications.
It is incorrect to tell the parent that there is nothing that can be done for croup.
Medical intervention can significantly improve the child's condition.
Choice D rationale:
Croup is primarily caused by viral infections, not bacterial infections.
Administering antibiotics without confirming a bacterial infection is inappropriate and contributes to antibiotic resistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A, “Your son has croup.”
Choice A rationale:
The symptoms described, including a barking cough, hoarseness, and inspiratory stridor, are classic signs of croup. Croup is a common respiratory condition in young children that leads to swelling of the larynx and trachea, causing the characteristic cough and stridor.
Choice B rationale:
While epiglottitis can present with respiratory distress, it is more commonly associated with high fever, severe sore throat, drooling, and difficulty swallowing, rather than a barking cough and stridor.
Choice C rationale:
Asthma typically presents with wheezing and difficulty exhaling, not the barking cough and inspiratory stridor seen in croup. Additionally, asthma is often associated with a history of allergies or atopic conditions, which are not mentioned in the scenario.
Choice D rationale:
Pneumonia usually presents with fever, cough producing phlegm, and crackles or wheezes on lung auscultation. The clear lungs on auscultation and the absence of productive cough make pneumonia less likely in this case.
In summary, the presentation of a barking cough, hoarseness, and inspiratory stridor in a young child who is in moderate respiratory distress with a recent onset of symptoms is most indicative of croup. This is supported by the age of the child and the clinical findings, which align with the typical presentation of croup.
Correct Answer is B
Explanation
Choice A rationale:
An oxygen saturation level of 95% is within the normal range (normal range is typically 95-100%).
While it is essential to monitor oxygen saturation, this value does not indicate worsening of the child's condition.
Choice B rationale:
A respiratory rate of 30 breaths per minute is above the normal range for a child and can indicate respiratory distress.
An increased respiratory rate is a concerning sign, suggesting the child is having difficulty breathing.
This finding indicates the child's condition is worsening and requires prompt attention.
Choice C rationale:
Mild retractions suggest that the child is working harder to breathe but may not necessarily indicate a severe worsening of the condition.
Retractions are a sign of increased respiratory effort but may vary in severity.
Choice D rationale:
A child with croup experiencing severe respiratory distress may not be able to speak in complete sentences due to the difficulty in breathing.
However, the ability to speak in complete sentences alone may not be a definitive indicator of worsening.
Monitoring the respiratory rate and effort is crucial in assessing the child's condition accurately.
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