A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
An infant who has pertussis and is receiving oxygen via nasal cannula.
A school-age child who has diabetes mellitus and requires blood glucose monitoring.
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
A toddler who has both arms in casts and needs to be fed his breakfast.
The Correct Answer is A
Choice A reason:
An infant who has pertussis and is receiving oxygen via nasal cannula: Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.
Choice B reason:
A school-age child who has diabetes mellitus and requires blood glucose monitoring: While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.
Choice C reason:
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions: Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.
Choice D reason:
A toddler who has both arms in casts and needs to be fed his breakfast: While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Purple striations: Purple striations, or stretch marks, are more commonly associated with Cushing’s syndrome, which involves excess cortisol production. Addison’s disease, on the other hand, is characterized by insufficient cortisol and aldosterone production.
Choice B reason:
Hirsutism: Hirsutism refers to excessive hair growth in women in areas where hair is normally minimal or absent. It is not typically associated with Addison’s disease. Hirsutism is more commonly linked to conditions involving excess androgens, such as polycystic ovary syndrome (PCOS).
Choice C reason:
Hyperpigmentation: Hyperpigmentation, or darkening of the skin, is a hallmark symptom of Addison’s disease. This occurs due to increased production of melanocyte-stimulating hormone (MSH) as a byproduct of elevated adrenocorticotropic hormone (ACTH) levels. The skin changes are often most noticeable in areas exposed to friction, such as the elbows, knees, and knuckles.
Choice D reason:
Intention tremors: Intention tremors, which occur during purposeful movement, are not typically associated with Addison’s disease. These tremors are more commonly seen in neurological conditions such as multiple sclerosis or cerebellar disorders.
Correct Answer is C
Explanation
Choice A reason: Exophthalmos
Exophthalmos, or bulging eyes, is not a typical symptom of hypothyroidism. Instead, it is commonly associated with hyperthyroidism, particularly Graves’ disease. In hypothyroidism, the thyroid gland is underactive, leading to a different set of symptoms.
Choice B reason: Photophobia
Photophobia, or sensitivity to light, is not a common symptom of hypothyroidism. While hypothyroidism can cause a variety of symptoms, photophobia is more often associated with conditions affecting the eyes or the nervous system.
Choice C reason: Lethargy
Lethargy, or extreme fatigue, is a common symptom of hypothyroidism. When the thyroid gland does not produce enough thyroid hormones, the body’s metabolism slows down, leading to feelings of tiredness and lack of energy. This is one of the hallmark symptoms of hypothyroidism and can significantly impact a person’s daily life.
Choice D reason: Weight Loss
Weight loss is not typically associated with hypothyroidism. In fact, weight gain is more common due to the slowed metabolism caused by an underactive thyroid. Individuals with hypothyroidism often experience difficulty losing weight and may gain weight even with a normal diet and exercise routine.
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