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
Rationale:
A. The child's throat pain is expected post-tonsillectomy and can be managed using analgesics or an ice collar. However, this is not a priority finding compared to frequent swallowing which may indicate bleeding which is a life-threatening complication of tonsillectomy.
B. Refusing clear liquids may indicate discomfort but is not as urgent as a potential increase in throat pain.
C. Crying often may be a response to discomfort but does not necessarily indicate a complication requiring immediate intervention.
D. This assessment finding indicates that the child might have bleeding in the throat, which is a life-threatening complication of tonsillectomy. The nurse should
Correct Answer is B
Explanation
Rationale:
A) Placing the child in a prone position can obstruct the airway and increase the risk of aspiration.
B) Clearing the area of hard objects helps prevent injury during a seizure.
C) Inserting a tongue blade between the teeth can cause oral trauma and should be avoided.
D) Minimizing movement of the limbs is not necessary during a seizure; the focus should be on ensuring safety and preventing injury.
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