A nurse is caring for a 3-year-old child.
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.
Irritability
Stridor
Temperature
Cough findings at 0800
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"}}
• Irritability: The child is restless and agitated, which is common in both upper and lower respiratory infections. Irritability reflects systemic response to infection, fever, and airway discomfort. It is an important indicator for monitoring respiratory status and overall well-being.
• Stridor: Inspiratory stridor is a hallmark of croup (acute laryngotracheobronchitis) due to airway inflammation and narrowing in the larynx and trachea. Stridor is typically absent in pneumonia, which primarily affects the lower airways.
• Temperature: The child has a low-grade fever (38.1–38.2° C), which is common in both croup and pneumonia. Fever indicates an inflammatory response to infection, and monitoring trends is important for evaluating disease progression or complications.
• Cough findings at 0800: The barking, non-productive cough is characteristic of croup, caused by inflammation of the upper airway. Pneumonia usually produces a productive cough with sputum and may involve lower respiratory symptoms like wheezing, crackles, or decreased breath sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Rationale for correct choices
• Mucous membranes pink and moist: Indicates adequate hydration and perfusion status. The improvement from the prior day’s assessment reflects positive fluid balance and appropriate nursing management.
• SpO2 98% on room air: Reflects adequate oxygenation without supplemental oxygen, demonstrating respiratory stability and effective tissue oxygen delivery.
Rationale for findings not indicating expected progress
• Nuchal rigidity present: Persistence of nuchal rigidity indicates ongoing meningeal irritation and does not reflect improvement. This finding requires continued monitoring and management to prevent complications.
• Temperature 38.9° C (102° F): The child remains febrile, indicating that infection is still present. Although other vital signs are improving, the fever demonstrates that full clinical resolution has not yet occurred.
Correct Answer is A
Explanation
A. Use open-ended questions when asking the adolescent about their health history: Open-ended questions encourage the adolescent to express concerns in their own words and promote trust and honesty. This approach supports accurate data collection and respects the adolescent’s developing autonomy and communication needs.
B. Communicate sympathy when asking the adolescent about their chief complaint: Expressing sympathy may unintentionally bias responses or shift focus away from objective data collection. Professional empathy and neutral listening are more appropriate to facilitate open communication.
C. Provide an opinion when discussing the adolescent's sexual history: Offering personal opinions can create discomfort, inhibit disclosure, and compromise therapeutic rapport. Sexual history should be explored in a nonjudgmental, factual manner to ensure accurate information.
D. Interview the parent first when collecting the adolescent's health history: Interviewing the parent first can limit the adolescent’s willingness to share sensitive information. Adolescents should be given the opportunity to speak privately to promote confidentiality and honest disclosure.
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