A nurse is caring for a 3-year-old child in the pediatric unit.
Based on the exhibits provided, which of the following findings are consistent with the child’s condition? Select all that apply.
Hoarse voice
Nasal flaring
Increased appetite
Sitting upright and leaning forward
Decreased respiratory rate
Correct Answer : A,B,D
Choice A rationale:
A hoarse voice is consistent with the child’s condition. The child has a frequent cough and stridor, which can cause irritation and inflammation of the vocal cords, leading to a hoarse voice.
Choice B rationale:
Nasal flaring is a sign of respiratory distress. It indicates that the child is working harder to breathe, which is consistent with the observed symptoms of stridor, cough, and mild intercostal retractions.
Choice C rationale:
Increased appetite is not consistent with the child’s condition. The child is refusing to eat or drink and appears fatigued, which is typical in cases of respiratory distress and illness.
Choice D rationale:
Sitting upright and leaning forward is a common position adopted by children in respiratory distress. This position helps to open the airway and makes breathing easier.
Choice E rationale:
Decreased respiratory rate is not consistent with the child’s condition. The child’s respiratory rate has increased from 20/min to 24/min, indicating increased effort to breathe due to respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Toddlers are typically more emotionally labile, meaning they experience rapid and intense emotional changes. This is a normal part of their development as they learn to navigate their emotions.
Choice B rationale
Frequent negative responses, such as saying “no” often, are common in toddlers. This behavior is part of their development as they assert their independence and test boundaries.
Choice C rationale
Toddlers are generally more resistant to routines as they seek to assert their independence and explore their environment. They may resist following set routines as a way of expressing their autonomy.
Choice D rationale
Increased dependency is not typical toddler behavior. Toddlers are usually striving for more independence and autonomy, even though they still rely on caregivers for support.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Keeping electrical wires hidden from view is essential to prevent toddlers from pulling on them, which can lead to electrical burns or other injuries. It is a proactive measure to ensure a safe environment for children who are naturally curious and prone to exploring with their hands.
Choice B rationale
Encouraging outdoor activities between the hours of 1100 and 1300 can expose toddlers to the sun’s peak intensity, increasing the risk of sunburn. It is safer to encourage outdoor activities outside these hours when the sun is less intense.
Choice C rationale
Setting the water heater to 60°C (140°F) is too high and poses a scalding risk. The recommended temperature to prevent burns is 49°C (120°F), which is hot enough for household use but not so hot as to cause immediate burns upon contact.
Choice D rationale
Turning pot handles toward the front of the stove is dangerous as it increases the risk of toddlers reaching up and pulling hot contents onto themselves. The correct practice is to turn pot handles toward the back of the stove to keep them out of reach of children.
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