A nurse is caring for a 3-year-old toddler who was newly admitted with pertussis in stage 2 (the paroxysmal stage) of the illness. Which of the following interventions should the nurse perform first?
Monitor intake and output.
Provide a nutritious meal.
Request play activities from the play therapist.
Allow the child to sleep and take, nap.
The Correct Answer is D
A. Monitor intake and output: Monitoring hydration is important in children with pertussis due to vomiting after coughing spells, but it is not the immediate priority in the paroxysmal stage. Stabilizing the child and minimizing triggers that worsen coughing takes precedence.
B. Provide a nutritious meal: During the paroxysmal stage, coughing fits can be severe and are often followed by vomiting. Offering meals too early may increase the risk of emesis and aspiration rather than support recovery.
C. Request play activities from the play therapist: Excessive stimulation, including play, can precipitate coughing paroxysms in pertussis. Activity should be limited during acute episodes to reduce respiratory distress.
D. Allow the child to sleep and take a nap: Rest and reduced stimulation are priorities during the paroxysmal stage of pertussis. Sleep helps conserve energy, decreases coughing triggers, and supports respiratory stability during this critical phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assess the stoma site monthly to minimize disruption to the client's routine: Stoma assessment should be performed at least daily, especially in pediatric clients, to monitor for changes in color, size, and skin integrity, rather than monthly.
B. Consult the wound-ostomy team for guidance on treating irritated or broken skin around the stoma: Involving a wound-ostomy-continence (WOC) nurse ensures specialized care for peristomal skin breakdown and helps prevent complications, which is essential for maintaining the stoma and surrounding tissue.
C. Change the ostomy appliance daily regardless of the condition of the stoma site: Routine daily changes are unnecessary and can irritate the skin. Appliance changes should be based on the condition of the skin and the integrity of the pouch system.
D. Empty the ostomy's stool output only when the collection appliance is full to capacity: Waiting until the appliance is full can increase the risk of leakage, skin breakdown, and odor. It is recommended to empty the pouch when it is one-third to one-half full.
Correct Answer is B
Explanation
A. Spine: Rhabdomyosarcoma rarely originates in the spine. While metastasis can occur to various sites, the spine is not a common primary location for this tumor in pediatric clients.
B. Head: Rhabdomyosarcoma most frequently arises in the head and neck region, including the orbit, nasopharynx, and paranasal sinuses. Tumors in this area often present with swelling, proptosis, or nasal obstruction, reflecting the typical manifestation sites in children.
C. Ribs: The ribs are an uncommon site for primary rhabdomyosarcoma. While thoracic involvement may occur secondary to metastasis, initial tumors in this location are rare.
D. Upper leg: Extremities can be affected by rhabdomyosarcoma, but the head and neck region is the most prevalent site. Tumors in the limbs are less common, though they may present with swelling or functional impairment if they occur there.
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