A nurse is caring for a 3-year-old child.
Exhibit 1
Exhibit 2 Nurses' Notes
0730:
Child presents to the emergency department (ED). Guardians report the child woke up coughing with a low-grade fever. Child appears alert and restless in guardian's arms.
Respirations easy, no cough noted.
0800:
Child became agitated. Hoarse cry noted with audible inspiratory stridor. Barking, nonproductive cough present.
For each of the following findings, click to specify if the finding is consistent with acute laryngotracheobronchitis or pneumonia. Each finding may support more than one disease process.
Assessment Findings: Acute laryngotracheobronchitis /Pneumonia
Irritability
Temperature
Cough findings at 0800
Stridor
The Correct Answer is A
A. This finding is consistent with both acute laryngotracheobronchitis and pneumonia, as both conditions can cause discomfort and distress in children.
B. Fever can be present in both acute laryngotracheobronchitis and pneumonia as they are both infections of the respiratory tract. It is a non-specific symptom that can occur with various respiratory illnesses.
C. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis is characterized by a barking, non-productive cough that worsens at night or with agitation, while pneumonia causes a productive cough that may be accompanied by chest pain or difficulty breathing.
D. This finding is more consistent with acute laryngotracheobronchitis than pneumonia, as acute laryngotracheobronchitis causes inflammation and narrowing of the upper airway, leading to a high-pitched sound during inhalation, while pneumonia affects the lower airway and does not usually cause stridor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Requesting assistance from the anesthesiologist may not be appropriate as they may not be as familiar with the specifics of the procedure as the provider performing it.
B. Explaining the procedure is not the nurse's role.
C. Witnessing the signature is a procedural task that does not address the guardian's need for understanding the necessity of the procedure.
D. Notifying the provider is the most appropriate action because they can provide a detailed explanation and answer specific questions the guardian may have, ensuring informed consent is truly informed.
Correct Answer is C
Explanation
A. Warming goat's milk before feeding does not address the issue of nutritional adequacy or the potential allergenicity of goat's milk.
B. Soy milk may not be suitable for infants under 12 months old due to potential allergenicity and nutritional concerns.
C. Commercially prepared infant formula is the most appropriate option for infants who are having difficulty with breastfeeding or require an alternative to breast milk.
D. Reinitiating breastfeeding may not be feasible or appropriate if the infant is already having difficulty eating.
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