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 C
Explanation
The correct answer is Choice C.
Choice A rationale
The inactivated polio virus (IPV) vaccine is typically administered at 2 months, 4 months, and 6-18 months of age, not at 12 months.
Choice B rationale
The hepatitis B vaccine is given at birth, 1-2 months, and 6-18 months of age.
Choice C rationale
The varicella (chickenpox) vaccine is recommended to be given at 12-15 months of age for the first dose.
Choice D rationale
The human papillomavirus (HPV) vaccine is recommended for preteens aged 11-12 years, not for infants.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Providing a doll for the 3-year-old child to imitate parental behaviors helps the child understand and adjust to the new role of being an older sibling. It allows the child to practice nurturing behaviors and can reduce feelings of jealousy or displacement by involving them in the care of the newborn.
Choice B rationale
Preparing the child for a change in all of their routines can be overwhelming and may cause unnecessary stress. It is more effective to maintain as much consistency as possible in the child’s routine while gradually introducing changes related to the new sibling.
Choice C rationale
Telling the child that they will now have a new playmate may create unrealistic expectations. A newborn is not immediately capable of playing, and this statement may lead to disappointment and frustration for the 3-year-old.
Choice D rationale
Waiting for the newborn to come home before moving the 3-year-old from the crib to a bed can create a sense of displacement and jealousy. It is better to make this transition well before the newborn’s arrival to allow the older child to adjust to the change independently of the new sibling.
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