A six-year-old girl is brought to the emergency department. She has a "frog-like croaking sound" on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should first do which of the following?
Get emergency equipment at the bedside.
Make her lie down and rest quietly.
Complete a thorough neurological assessment.
Auscultate her lungs and prepare for administering oxygen.
The Correct Answer is A
Choice A reason: This is the correct answer because the girl's symptoms indicate that she may have epiglottitis, a life-threatening condition that causes swelling of the epiglottis and obstructs the airway. The nurse should be prepared for a possible intubation or tracheostomy.
Choice B reason: This is not the correct answer because making the girl lie down and rest quietly may worsen her respiratory distress and anxiety. The girl should be allowed to sit in a position of comfort and ease of breathing.
Choice C reason: This is not the correct answer because a thorough neurological assessment is not the priority in this situation. The nurse should focus on the girl's airway, breathing, and circulation.
Choice D reason: This is not the correct answer because auscultating the lungs and preparing for administering oxygen may not be sufficient to manage the girl's airway obstruction. The nurse should also have emergency equipment ready and call for assistance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is not a relevant question for the admission history, as it does not address the child's current condition or treatment plan. It may also be perceived as insensitive or judgmental by the parents.
Choice B reason: This is not a pertinent question for the admission history, as it does not relate to the child's medical history or needs. It may also be seen as intrusive or irrelevant by the parents.
Choice C reason: This is an appropriate question for the admission history, as it acknowledges the cultural beliefs and practices of the parents and the child. It also helps the nurse to identify any potential interactions or conflicts between the tribal healer's recommendations and the medical treatment.
Choice D reason: This is a valid question for the admission history, as it informs the nurse of any alternative therapies or substances that the child may have received or ingested. It also helps the nurse to assess the effectiveness and safety of the herbal remedies, and to prevent any adverse effects or interactions with the prescribed medications.
Correct Answer is A
Explanation
Choice A reason: This is the most comprehensive and accurate way of assessing a child's pain, as it takes into account the child's own perception, the parent's observation, and the objective signs of pain.
Choice B reason: This is not the best approach, as the parents may not be able to accurately rate the child's pain, especially if the child is too young or has communication difficulties.
Choice C reason: This is not the best approach, as behavioral clues may not always reflect the intensity or quality of pain, and may be influenced by other factors such as fear, anxiety, or coping strategies.
Choice D reason: This is not the best approach, as physiological measures may not always correlate with pain, and may be affected by other variables such as medication, stress, or illness.
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