A nurse is assessing a 4-year-old client admitted to the pediatric unit for respiratory distress. Which of the following findings should be addressed immediately?
Stridor during inspiration.
A wet, productive cough.
A fever of 38.5°C (101.3°F).
Irritability reported by the caregiver.
The Correct Answer is A
Choice A rationale: Stridor during inspiration is a high-pitched, harsh sound caused by an upper airway obstruction. This is a critical finding that requires immediate attention, as it indicates compromised airflow potentially due to conditions like croup, epiglottitis, or foreign body aspiration. Left untreated, the obstruction can worsen, leading to severe hypoxia or respiratory failure. Prompt evaluation and intervention, such as securing the airway, are essential to ensure the child's safety and prevent life-threatening complications.
Choice B rationale: A wet, productive cough is typically associated with lower respiratory tract infections, such as bronchitis or pneumonia. While it warrants medical attention and treatment, it is not an immediate threat to the airway or oxygenation compared to stridor. Management often includes supportive care, hydration, and possibly antibiotics. However, this finding does not pose the acute risk that stridor represents in terms of respiratory distress and airway compromise.
Choice C rationale: A fever of 38.5°C (101.3°F) is a common finding in pediatric clients with infections. It indicates an inflammatory response to illness but is not immediately life-threatening. Fever management involves antipyretics, hydration, and monitoring for signs of more severe infection or sepsis. While elevated temperature requires attention, it does not carry the same urgency as stridor, which signals potential airway obstruction.
Choice D rationale: Irritability reported by the caregiver is a nonspecific symptom that may result from various causes, including pain, discomfort, or fever. While it suggests the child may be unwell, it does not directly indicate a critical condition or imminent danger. Monitoring and addressing the underlying cause of irritability are important, but this finding does not necessitate the same immediate response as stridor, which directly affects airway patency and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A hard-boiled egg is rich in proteins, providing essential amino acids for growth and development in toddlers. It is also soft and easy to chew, reducing choking hazards. Nutritionally, eggs contribute to overall health and meet dietary recommendations for young children.
Choice B rationale
Grapes pose a significant choking risk for toddlers due to their size and slippery texture. While they are nutritious, alternative preparations such as slicing into smaller pieces are necessary for safe consumption by toddlers.
Choice C rationale
Raw carrots are a common choking hazard for toddlers due to their hardness and size. Cooked carrots or smaller, softened pieces are safer alternatives to provide the same nutritional benefits without the risk.
Choice D rationale
Popcorn is unsuitable for toddlers as its small kernels and inconsistent texture present a choking hazard. Despite being a snack option for older children, it lacks the safety required for young children during their developmental stage.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
Obtaining daily weights is vital for monitoring fluid status and nutritional health, especially in children prone to rapid physiological changes. It provides insight into trends such as dehydration, edema, or growth concerns.
Choice B rationale
Blood pressure every 8 hours is a less frequent monitoring intervention and may not be sufficient for detecting acute changes. Vital signs often require more regular assessment in pediatric care.
Choice C rationale
Maintaining seizure precautions ensures immediate response readiness for children with neurological risks or past seizure history. It involves safeguards like padded bed rails and accessible emergency equipment to mitigate injury risks during seizures.
Choice D rationale
Sodium-restricted diets are less commonly applied in pediatric cases unless specifically indicated for conditions like nephrotic syndrome or severe hypertension. Routine care does not involve universal dietary sodium modifications.
Choice E rationale
Strict bed rest may lead to deconditioning and is only suitable for specific diagnoses necessitating immobility. Pediatric care often promotes movement within safe limits to prevent complications like pressure injuries.
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