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 B
Explanation
A. Identify cues in the client's behavior that might have warned them that he was contemplating suicide: While identifying cues in the client's behavior is important for understanding potential risk factors and improving suicide prevention measures in the future, it is not the priority intervention immediately following a client's suicide. Staff members may need support and debriefing to process the emotional impact of the event before effectively analyzing cues and implementing changes.
B. Provide professional counseling for staff members: Following a client's suicide, the priority intervention is to ensure the well-being of the staff members who may be experiencing emotional distress, guilt, or trauma as a result of the incident. Professional counseling provides an opportunity for staff to process their feelings, receive support, and develop coping strategies to manage the emotional impact of the event.
C. Change policies for staff observation of clients who are suicidal: While reviewing and updating policies for staff observation of suicidal clients is important for improving safety measures, it is not the immediate priority following a client's suicide. Policy changes should be informed by a thorough review of the incident, including staff debriefing, analysis of contributing factors, and consultation with mental health professionals.
D. Give the family an opportunity to talk about their feelings: While providing support to the client's family is important, especially in the aftermath of a suicide, it is not the priority intervention for staff immediately following the incident. Staff members need to address their own emotional needs and well-being first before they can effectively support the client's family.
Correct Answer is C
Explanation
A. Using frequent touch to provide client support: While touch can be comforting for some clients, individuals with schizophrenia, especially those experiencing paranoid delusions, may interpret touch as threatening or intrusive. Therefore, using frequent touch may exacerbate the client's paranoia and increase their distress.
B. Directly telling the client that delusions are not real: Directly challenging the client's delusions may cause them to become defensive or agitated. It is unlikely to be effective in changing the client's beliefs and may damage the therapeutic relationship. Instead, the nurse should use therapeutic communication techniques to explore the client's perceptions and validate their feelings while gently offering alternative perspectives.
C. Limiting the number of questions asked during assessments: Individuals experiencing frequent hallucinations and paranoid delusions may have difficulty concentrating and processing information. Limiting the number of questions asked during assessments reduces cognitive overload and helps prevent overwhelming the client. The nurse should prioritize asking clear, concise questions relevant to the client's immediate needs.
D. Placing the client in seclusion if visual hallucinations are present: Seclusion should only be used as a last resort and when absolutely necessary to ensure the safety of the client or others. It is not an appropriate intervention for managing hallucinations alone. Instead, the nurse should employ therapeutic communication techniques, provide a safe and supportive environment, and use prescribed medications as indicated to manage the client's symptoms.
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