A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?

Flaring of the nares.

Bilateral bronchial breath sounds.

Diaphragmatic respirations.

Resting respiratory rate of 35 breaths/minute.

Answer and Explanation

The Correct Answer is A

Flaring of the nares is a sign of respiratory distress in children. It indicates that the child is working harder to breathe.
Choice B rationale
Bilateral bronchial breath sounds are normal and do not indicate acute respiratory distress.
Choice C rationale
Diaphragmatic respirations are normal in children and do not indicate acute respiratory distress.
Choice D rationale
A resting respiratory rate of 35 breaths/minute is within the normal range for a preschoolaged child and does not indicate acute respiratory distress.

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Correct Answer is C

Explanation

Choice A rationale
Purulent secretions are not typically associated with epiglottitis. Epiglottitis is an inflammation and swelling of the epiglottis and does not usually produce purulent secretions.
Choice B rationale
While a child with epiglottitis may appear anxious due to difficulty breathing, apprehension is not a specific symptom of epiglottitis.
Choice C rationale
A thick, muffled voice is a common symptom of epiglottitis. The inflammation and swelling of the epiglottis can affect the child’s voice, making it sound thick and muffled.
Choice D rationale
Wheezing is not typically a symptom of epiglottitis. While breathing difficulties are common in epiglottitis, they are usually due to the swelling of the epiglottis rather than constriction of the airways, which causes wheezing.

A. Obtain blood cultures. B. Cover the lesion with a dressing. C. Administer penicillin. D. Prepare for a cesarean section.

Correct Answer is D

Explanation

Choice A rationale
Obtaining blood cultures is not the first action to take in this situation. Blood cultures would be used to identify a bloodstream infection, which is not indicated by the client’s current symptoms.
Choice B rationale
Covering the lesion with a dressing is not the appropriate action. Herpes lesions are highly contagious, and covering them does not eliminate the risk of transmission during vaginal delivery.
Choice C rationale
Administering penicillin is not the appropriate action. Penicillin is an antibiotic used to treat bacterial infections, not viral infections like herpes.
Choice D rationale
Preparing for a cesarean section is the correct action. A cesarean section is recommended for women with active genital herpes lesions or prodromal symptoms at the time of labor to prevent transmission of the virus to the newborn during delivery.

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A parent rushes their pre-school age child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A parent rushes their pre-school age child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?