A nurse is caring for a toddler who has acute laryngotracheobonchitis after a repair of an intussusception. Which of the indicates that the treatment has been effective?
Barking cough
Decreased stridor
Decreased temperature
Improved hydration
The Correct Answer is B
A. Barking cough: A barking cough is a characteristic symptom of acute laryngotracheobronchitis (croup), indicating inflammation of the upper airway. While it may improve with treatment, it is not necessarily an indication that the treatment has been effective on its own.
B. Decreased stridor: Stridor is a high-pitched, wheezing sound heard during inspiration and indicates upper airway obstruction. In acute laryngotracheobronchitis, stridor is a prominent symptom. Decreased stridor suggests that the airway obstruction is resolving, which indicates that the treatment has been effective.
C. Decreased temperature: While fever may be present in some cases of acute laryngotracheobronchitis, it is not a defining characteristic. A decreased temperature alone does not necessarily indicate that the treatment has been effective in managing the condition.
D. Improved hydration: Hydration is important in managing any illness, including acute laryngotracheobronchitis, but improved hydration alone does not indicate that the treatment has been effective in resolving the condition. It may be an important aspect of supportive care but does not directly reflect the resolution of airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Expressive affect: Individuals with autism spectrum disorder (ASD) often have difficulty expressing their emotions in a typical manner. They may display a restricted range of facial expressions or have difficulty conveying emotions through facial expressions and gestures. However, "expressive affect" typically refers to the appropriate display of emotions, which may not be characteristic of ASD.
B. Ambivalence: Ambivalence refers to conflicting feelings or attitudes about a situation or person. While individuals with ASD may experience a range of emotions, including ambivalence, it is not a specific characteristic associated with the disorder. Ambivalence is a common human experience and may occur in individuals with or without ASD.
C. Echolalia: Echolalia is a common communication characteristic observed in individuals with ASD. It involves the repetition or echoing of words or phrases spoken by others. This behavior may occur immediately after hearing the words or phrases (immediate echolalia) or may be delayed. Echolalia can serve various functions, including communication, self-regulation, or expression of anxiety.
D. Associative looseness: Associative looseness is a thought disorder characterized by a lack of logical connection between thoughts and ideas. It is typically associated with conditions such as schizophrenia rather than ASD. Individuals with ASD may exhibit difficulties with social communication, including challenges in maintaining conversations or understanding social cues, but this is different from the disorganized thinking observed in associative looseness.
Correct Answer is D
Explanation
A. Skin integrity: Skin integrity can be an indicator of dehydration, as dehydrated skin may appear dry and lack elasticity. However, skin turgor is not the most reliable indicator of fluid loss because it can be influenced by factors such as age and overall health. For example, infants and older adults may have decreased skin turgor due to a loss of skin elasticity, even if they are adequately hydrated.
B. Blood pressure: Blood pressure can decrease with significant fluid loss because there is less fluid volume to fill the arteries, leading to a drop in blood pressure. However, blood pressure is not the most reliable indicator of fluid loss because it can be influenced by many other factors, such as heart function and vascular resistance. Additionally, blood pressure may not change significantly until severe dehydration occurs.
C. Respiratory rate: An increased respiratory rate can be a sign of dehydration because the body may try to compensate for fluid loss by increasing the respiratory rate to deliver more oxygen to the tissues. However, an increased respiratory rate is a nonspecific symptom that can be associated with many other conditions, such as fever, pain, or lung disease. Therefore, it is not the most reliable indicator of fluid loss.
D. Body weight: Body weight is the most reliable indicator of fluid loss. This is because water makes up a significant portion of body weight, so a decrease in body weight is a direct indication of fluid loss. In infants, a rapid change in weight is often the first sign of fluid imbalance because they have a higher percentage of body water and a higher metabolic rate compared to adults. A 5% weight loss is considered mild dehydration, 10% is moderate, and 15% or more is severe. Therefore, regular monitoring of an infant’s weight is crucial when assessing for dehydration.
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