A nurse is caring for a 2-year-old male toddler in the emergency department.
Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)
Nasal flaring
Retractions
Oxygen saturation
Breath sounds in bilateral bases
Respiratory rate
Heart rate
Correct Answer : C,D,E
Choice A rationale:
Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.
Choice B rationale:
Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.
Choice C rationale:
Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.
Choice D rationale:
Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.
Choice E rationale:
Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.
Choice F rationale:
Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Over-riding suture lines are not a typical manifestation of hydrocephalus. This condition involves the accumulation of cerebrospinal fluid within the brain’s ventricles, leading to increased intracranial pressure.
Choice B rationale
A backward sloping appearance of the forehead is not associated with hydrocephalus. This condition typically presents with an enlarged head circumference due to fluid accumulation.
Choice C rationale
Dilated scalp veins are a common manifestation of hydrocephalus. The increased intracranial pressure causes the veins to become more prominent and visible.
Choice D rationale
Hypertension is not a primary symptom of hydrocephalus in newborns. The condition primarily affects the brain and skull, leading to symptoms like an enlarged head, bulging fontanelles, and dilated scalp veins.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Environment plays a significant role in a child’s growth and development, including factors like socioeconomic status, access to education, and living conditions. However, it can be altered to some extent.
Choice B rationale
Genetics is the largest factor impacting growth and development that cannot be altered. Genetic factors determine physical characteristics, susceptibility to certain diseases, and overall growth patterns.
Choice C rationale
Socialization influences a child’s development, including social skills and behavior. While important, it can be influenced and altered through various interventions.
Choice D rationale
Nutrition is crucial for growth and development, affecting physical and cognitive development. However, it can be modified through dietary changes and interventions.
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