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 D
Explanation
The correct answer is Choice D.
Choice A rationale
Asking the child’s parent to leave the room during the procedure may increase the child’s anxiety and make the procedure more traumatic. Parental presence can provide comfort and reduce anxiety.
Choice B rationale
Performing the procedure in the unit’s playroom may not provide the necessary equipment and sterile environment required for a venipuncture. It is important to perform the procedure in a controlled and sterile environment.
Choice C rationale
Explaining the procedure in detail to the child 3 hours prior to the procedure may increase anxiety and anticipation, making the procedure more traumatic. It is better to explain the procedure closer to the time of the procedure.
Choice D rationale
Applying a topical anesthetic cream 1 hour prior to the procedure helps reduce pain and discomfort during the venipuncture, promoting atraumatic care. This approach minimizes the child’s pain and anxiety.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Restricting the child’s strenuous activities for 3 days is important, but it is not the priority. Monitoring for signs of impaired circulation or complications is more critical.
Choice B rationale
Using a hair dryer on a cool setting to relieve itching can be helpful, but it is not the priority. The priority is to monitor for signs of impaired circulation.
Choice C rationale
Monitoring for pallor or swelling in the child’s affected hand is the priority because it can indicate impaired circulation or compartment syndrome, which are serious complications that require immediate attention.
Choice D rationale
Examining the child for skin irritation at the cast edges is important to prevent complications, but it is not the priority over monitoring for circulation and potential complications. .
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