A patient is admitted from the emergency room with laryngotracheobronchitis. The patient has a brassy cough, stridor, and substernal retractions. The child is receiving an intravenous infusion and is placed in a mist tent. Which observation would indicate a worsening of the patient's condition?
An increasing pulse rate.
Mouth breathing.
An increase in nasal discharge.
A hoarse cry.
The Correct Answer is A
Choice A rationale:
An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.
Choice B rationale:
Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.
Choice C rationale:
An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.
Choice D rationale:
A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
While educating caregivers on sensory impairment is important for an infant with myelomeningocele, preventing infection takes precedence as the priority nursing intervention.
Choice B rationale:
The correct answer. Preventing infection at the site of the myelomeningocele is crucial to avoid potentially life-threatening complications, such as meningitis. The exposed neural tissue poses a significant infection risk.
Choice C rationale:
Correcting joint contractures is important but is a secondary concern compared to preventing infection, which can have more immediate and severe consequences.
Choice D rationale:
Measuring daily head circumference is important to monitor for hydrocephalus in these infants, but preventing infection remains the higher priority.
Correct Answer is C
Explanation
Choice A rationale:
Placing the infant on her left side with a pillow supporting her back after feeding is appropriate as it prevents aspiration and reflux due to gravity.
Choice B rationale:
Covering the cast with a towel to prevent accidental soiling is a sensible action, ensuring the cast remains clean and dry.
Choice C rationale:
The mother using the football hold to position the infant securely to one side might hinder the cast's stability and could potentially cause discomfort or displacement.
Choice D rationale:
Supporting both the infant's head and cast when leaning her forward for burping is essential to maintain the cast's integrity and to prevent strain on the infant's body.
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